Provider Demographics
NPI:1720893050
Name:LIDDELL, LEILANI (CRADC)
Entity type:Individual
Prefix:
First Name:LEILANI
Middle Name:
Last Name:LIDDELL
Suffix:
Gender:
Credentials:CRADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9733 SAINT CHARLES ROCK RD
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE HILLS
Mailing Address - State:MO
Mailing Address - Zip Code:63114-2625
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9733 SAINT CHARLES ROCK RD
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE HILLS
Practice Address - State:MO
Practice Address - Zip Code:63114-2625
Practice Address - Country:US
Practice Address - Phone:314-574-5926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-12
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)