Provider Demographics
NPI:1295863157
Name:LEEDS, ANDREA (LCSW)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:LEEDS
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 1:1607 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5111
Mailing Address - Country:US
Mailing Address - Phone:208-336-5533
Mailing Address - Fax:208-947-4290
Practice Address - Street 1:1607 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5111
Practice Address - Country:US
Practice Address - Phone:208-336-5533
Practice Address - Fax:208-947-4290
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW1060101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010145219OtherREGENCEMENTALHEALTH
IDL3308OtherBCI