Mallory Leatherman 062519

Key facts

NPI

1659932069

Entity type

Individual (NPI type 1)

Primary specialty

Mental Health Counselor 101YM0800X

Practice address

3900 Hursh Rd
Fort Wayne, IN 46845-9677

Phone

(260) 637-3608

NPI assigned

Jun 26, 2019

Sex

Female

Sole proprietor

No

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• A.W. Holdings, LLC Mental Health Counselor · Fort Wayne, IN · NPI 1013578749
  NPD (past) MENTAL HEALTH

Medicare participation

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD)

No

Practice roles

Specialties & licenses

Addresses

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Jun 26, 2019.

{
    "created_epoch": "1561507200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1561507200000",
    "number": "1659932069",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8515 BLUFFTON RD",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468093022"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3900 HURSH RD",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468459677",
            "telephone_number": "260-637-3608"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "LEATHERMAN 062519",
        "first_name": "MALLORY",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2019-06-26",
        "last_updated": "2019-06-26",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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All providers in Fort Wayne, IN · Mental Health Counselor in Indiana