Provider Demographics
NPI:1366187676
Name:CLARK, LEACHA M (ASW)
Entity type:Individual
Prefix:
First Name:LEACHA
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4380 BASTILLE WALK
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-2122
Mailing Address - Country:US
Mailing Address - Phone:209-687-1754
Mailing Address - Fax:
Practice Address - Street 1:4001 CA-104
Practice Address - Street 2:
Practice Address - City:IONE
Practice Address - State:CA
Practice Address - Zip Code:95640
Practice Address - Country:US
Practice Address - Phone:209-274-4911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-02
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106588390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program