1386755122 NPI number — LISA ANNE LEIDECKER LPC, LCADC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386755122 NPI number — LISA ANNE LEIDECKER LPC, LCADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEIDECKER
Provider First Name:
LISA
Provider Middle Name:
ANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC, LCADC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386755122
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13 CLAVENDON CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLETOWN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07748-3533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-568-1166
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
51 UPPER MONTCLAIR PLZ
Provider Second Line Business Practice Location Address:
SUITE 21
Provider Business Practice Location Address City Name:
UPPER MONTCLAIR
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07043-1343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-568-1166
Provider Business Practice Location Address Fax Number:
732-957-9119
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  37LC00057200 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 101YP2500X , with the licence number: 37PC00020000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)





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