Provider Demographics
NPI:1215989694
Name:MACK-LEONARD, JOYCE (MFS LMFT)
Entity type:Individual
Prefix:MRS
First Name:JOYCE
Middle Name:
Last Name:MACK-LEONARD
Suffix:
Gender:F
Credentials:MFS LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 CORDER RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-3785
Mailing Address - Country:US
Mailing Address - Phone:478-929-4962
Mailing Address - Fax:478-928-4960
Practice Address - Street 1:402 CORDER RD
Practice Address - Street 2:SUITE 200
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-3785
Practice Address - Country:US
Practice Address - Phone:478-929-4962
Practice Address - Fax:478-928-4960
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT 000718106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA488595116AMedicaid