Provider Demographics
NPI:1679103691
Name:MCMANUS, LEECHANN (EXECUTIVE DIRECTOR)
Entity type:Individual
Prefix:MR
First Name:LEECHANN
Middle Name:
Last Name:MCMANUS
Suffix:
Gender:M
Credentials:EXECUTIVE DIRECTOR
Other - Prefix:MR
Other - First Name:KEDIAN
Other - Middle Name:DARIUS
Other - Last Name:TABORN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CFO
Mailing Address - Street 1:440 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-6806
Mailing Address - Country:US
Mailing Address - Phone:704-257-1086
Mailing Address - Fax:
Practice Address - Street 1:440 CHARLES ST
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-6806
Practice Address - Country:US
Practice Address - Phone:704-257-1086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health