Provider Demographics
NPI:1154476182
Name:NEUSTAEDTER, LETA M (LCSW)
Entity Type:Individual
Prefix:
First Name:LETA
Middle Name:M
Last Name:NEUSTAEDTER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 MAIN ST
Mailing Address - Street 2:#231
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5720
Mailing Address - Country:US
Mailing Address - Phone:208-697-4703
Mailing Address - Fax:
Practice Address - Street 1:910 MAIN ST
Practice Address - Street 2:#231
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5720
Practice Address - Country:US
Practice Address - Phone:208-697-4703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-285201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical