Provider Demographics
NPI:1215986203
Name:LEAVITT, MELODY ANN (LSCSW, ACSW)
Entity type:Individual
Prefix:
First Name:MELODY
Middle Name:ANN
Last Name:LEAVITT
Suffix:
Gender:F
Credentials:LSCSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64
Mailing Address - Street 2:
Mailing Address - City:MOUND CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66056-0064
Mailing Address - Country:US
Mailing Address - Phone:913-795-2567
Mailing Address - Fax:
Practice Address - Street 1:506 1/2 MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUND CITY
Practice Address - State:KS
Practice Address - Zip Code:66056-6254
Practice Address - Country:US
Practice Address - Phone:913-795-4414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLSCSW 07101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS044592Medicare ID - Type Unspecified