Provider Demographics
NPI:1366675241
Name:LEIDAL, FREDERICK G (PHD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:G
Last Name:LEIDAL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5935 N LARIAT DR
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80108-9367
Mailing Address - Country:US
Mailing Address - Phone:720-988-3885
Mailing Address - Fax:866-836-3632
Practice Address - Street 1:9101 E KENYON AVE STE 2900
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80237-1855
Practice Address - Country:US
Practice Address - Phone:720-489-7756
Practice Address - Fax:866-836-3632
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-26
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4168103G00000X
CO2301103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist