Provider Demographics
NPI:1396131108
Name:PREMIER LEADERSHIP ACADEMY, IN
Entity type:Organization
Organization Name:PREMIER LEADERSHIP ACADEMY, IN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KRESLYN
Authorized Official - Middle Name:NICHOLE
Authorized Official - Last Name:KELLEY-ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:256-288-3281
Mailing Address - Street 1:2049 MAX LUTHER DR NW
Mailing Address - Street 2:SUITE A
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35810-3801
Mailing Address - Country:US
Mailing Address - Phone:256-288-3281
Mailing Address - Fax:256-288-3283
Practice Address - Street 1:2049 MAX LUTHER DR NW
Practice Address - Street 2:SUITE A
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35810-3801
Practice Address - Country:US
Practice Address - Phone:256-288-3281
Practice Address - Fax:256-288-3283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-08
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALLPC1530251S00000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty