Provider Demographics
NPI:1174957609
Name:LEININGER, SHELLEY LEIGH (PHD)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:LEIGH
Last Name:LEININGER
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:PO BOX 601372
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1372
Mailing Address - Country:US
Mailing Address - Phone:704-355-9047
Mailing Address - Fax:704-355-9458
Practice Address - Street 1:1100 BLYTHE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5814
Practice Address - Country:US
Practice Address - Phone:704-355-9047
Practice Address - Fax:704-355-9458
Is Sole Proprietor?:No
Enumeration Date:2013-09-03
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4492103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1174957609Medicaid
SCPS0535Medicaid
SCPS0535Medicaid