1720099203 NPI number — MS. SALLY JO LEYSE LCPC

Table of content: MS. SALLY JO LEYSE LCPC (NPI 1720099203)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720099203 NPI number — MS. SALLY JO LEYSE LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEYSE
Provider First Name:
SALLY
Provider Middle Name:
JO
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEYSE
Provider Other First Name:
SALLY
Provider Other Middle Name:
JO
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCPC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1720099203
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601A PIONEER MOUNTAIN LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JEROME
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83338-6557
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-420-5902
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601A PIONEER MOUNTAIN LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JEROME
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83338-6557
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-420-5902
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/10/2006

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: 101YM0800X , with the licence number:  LCPC-215 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000010017683 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 12249540 . This is a "CAQH" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: Q215-6 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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