Provider Demographics
NPI:1285107953
Name:DIERCKS, LEAH ELAINE (LCSW)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:ELAINE
Last Name:DIERCKS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 OLD MILL RD
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:MT
Mailing Address - Zip Code:59063-8033
Mailing Address - Country:US
Mailing Address - Phone:406-780-1205
Mailing Address - Fax:
Practice Address - Street 1:1925 GRAND AVE STE 100
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-2763
Practice Address - Country:US
Practice Address - Phone:406-780-1205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-06
Last Update Date:2019-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCSW-LIC-366361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical