Provider Demographics
NPI:1104168186
Name:LEIBFRIED, SAMANTHA (LPC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:LEIBFRIED
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 1:702 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:WI
Mailing Address - Zip Code:53813-2186
Mailing Address - Country:US
Mailing Address - Phone:608-723-4433
Mailing Address - Fax:608-535-6862
Practice Address - Street 1:702 S MADISON ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:WI
Practice Address - Zip Code:53813-2186
Practice Address - Country:US
Practice Address - Phone:608-723-4433
Practice Address - Fax:608-535-6862
Is Sole Proprietor?:No
Enumeration Date:2013-03-18
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1689-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1104168186Medicaid