Provider Demographics
NPI:1538411590
Name:MARTIN-LECKENBY, LISA J (LCSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:J
Last Name:MARTIN-LECKENBY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 E BATTLEFIELD ST STE 102B
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-4829
Mailing Address - Country:US
Mailing Address - Phone:417-597-4572
Mailing Address - Fax:
Practice Address - Street 1:158 N ADAMS AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-3021
Practice Address - Country:US
Practice Address - Phone:417-597-4572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20010257831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical