Provider Demographics
NPI:1104172980
Name:RISTAU, LEISHA R (LISW)
Entity type:Individual
Prefix:
First Name:LEISHA
Middle Name:R
Last Name:RISTAU
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:LEISHA
Other - Middle Name:R
Other - Last Name:STAPLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW
Mailing Address - Street 1:2425 N ANKENY BLVD STE 106
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-4711
Mailing Address - Country:US
Mailing Address - Phone:515-489-4602
Mailing Address - Fax:
Practice Address - Street 1:2425 N ANKENY BLVD STE 106
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-4722
Practice Address - Country:US
Practice Address - Phone:515-489-4602
Practice Address - Fax:515-512-1504
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0079311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical