Provider Demographics
NPI:1386755122
Name:LEIDECKER, LISA ANNE (LPC, LCADC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:LEIDECKER
Suffix:
Gender:F
Credentials:LPC, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 CLAVENDON CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07748-3533
Mailing Address - Country:US
Mailing Address - Phone:973-568-1166
Mailing Address - Fax:
Practice Address - Street 1:51 UPPER MONTCLAIR PLZ
Practice Address - Street 2:SUITE 21
Practice Address - City:UPPER MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07043-1343
Practice Address - Country:US
Practice Address - Phone:973-568-1166
Practice Address - Fax:732-957-9119
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00057200101YA0400X
NJ37PC00020000101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional