Provider Demographics
NPI:1588875793
Name:LEATH, MELISSA ANNE (PHD)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANNE
Last Name:LEATH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1419 WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-1410
Mailing Address - Country:US
Mailing Address - Phone:502-458-3706
Mailing Address - Fax:
Practice Address - Street 1:1169 EASTERN PKWY
Practice Address - Street 2:MEDICAL ARTS BLDG SUITE 1147
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1417
Practice Address - Country:US
Practice Address - Phone:502-451-9222
Practice Address - Fax:502-451-4499
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY691103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist