Provider Demographics
NPI:1174513154
Name:LEIMBACH, CAROL SHEPPARD (MFT)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:SHEPPARD
Last Name:LEIMBACH
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-6214
Mailing Address - Country:US
Mailing Address - Phone:707-426-0763
Mailing Address - Fax:707-426-0951
Practice Address - Street 1:628 WEBSTER ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-6214
Practice Address - Country:US
Practice Address - Phone:707-426-0763
Practice Address - Fax:707-426-0951
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 23412106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA155811OtherVALUE OPTIONS