Provider Demographics
NPI:1184666166
Name:LEA, ROBERT (EDD, LP)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:LEA
Suffix:
Gender:M
Credentials:EDD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1636 W OLD LIBERTY RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ELDERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21784-9335
Mailing Address - Country:US
Mailing Address - Phone:410-635-8400
Mailing Address - Fax:410-635-8444
Practice Address - Street 1:1636 W OLD LIBERTY RD
Practice Address - Street 2:SUITE 1
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-9335
Practice Address - Country:US
Practice Address - Phone:410-635-8400
Practice Address - Fax:410-635-8444
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02076103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD024202100Medicaid
MD983M803FMedicare ID - Type Unspecified