Provider Demographics
NPI:1962529503
Name:DIEDERICH, LEANN TERRY (PHD)
Entity type:Individual
Prefix:
First Name:LEANN
Middle Name:TERRY
Last Name:DIEDERICH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 655
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:PA
Mailing Address - Zip Code:16851-0655
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:720 PIKE STREET
Practice Address - Street 2:SUITE 3
Practice Address - City:LEMONT
Practice Address - State:PA
Practice Address - Zip Code:16851
Practice Address - Country:US
Practice Address - Phone:814-777-8899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017258103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling