Provider Demographics
NPI:1154083897
Name:LEIDAL, BRIAN DOUGLAS (MA LPC CMHC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:DOUGLAS
Last Name:LEIDAL
Suffix:
Gender:M
Credentials:MA LPC CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 WOOD ST APT 3
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:RI
Mailing Address - Zip Code:02809-3169
Mailing Address - Country:US
Mailing Address - Phone:313-969-2288
Mailing Address - Fax:
Practice Address - Street 1:405 LITTLE LAKE DR STE A
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-6220
Practice Address - Country:US
Practice Address - Phone:734-719-0380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-11
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMHC01319101YM0800X
UT10460707-6004101YM0800X
COLPC.0013400101YP2500X
MI6401223256101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional