Provider Demographics
NPI:1730650763
Name:LEATH, HOLLE (LPC)
Entity type:Individual
Prefix:
First Name:HOLLE
Middle Name:
Last Name:LEATH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 NEW FRANKLIN RD # 1028
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-2344
Mailing Address - Country:US
Mailing Address - Phone:706-350-4014
Mailing Address - Fax:706-786-0870
Practice Address - Street 1:705 COLQUITT ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241-3605
Practice Address - Country:US
Practice Address - Phone:706-350-4014
Practice Address - Fax:706-786-0870
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC011079101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty