Provider Demographics
NPI:1871066449
Name:LEAKS, EBONY
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:LEAKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 JOHN WESLEY AVE
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30337-3605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1919 JOHN WESLEY AVE
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30337-3605
Practice Address - Country:US
Practice Address - Phone:314-584-9294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist