Provider Demographics
NPI:1235289083
Name:LEIDENFROST, COREY MARK (MA)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:MARK
Last Name:LEIDENFROST
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1711
Mailing Address - Country:US
Mailing Address - Phone:716-856-4494
Mailing Address - Fax:716-842-1277
Practice Address - Street 1:620 TRONOLONE PL
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14301-1910
Practice Address - Country:US
Practice Address - Phone:716-205-0825
Practice Address - Fax:716-205-0824
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00030241501OtherUNIVERA
NY000506354005OtherCOMMUNITY BLUE