Provider Demographics
NPI:1396377164
Name:LEYDERMAN, MARIYA
Entity Type:Individual
Prefix:
First Name:MARIYA
Middle Name:
Last Name:LEYDERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:974 BRECKENRIDGE LN STE 171
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4619
Mailing Address - Country:US
Mailing Address - Phone:502-694-9432
Mailing Address - Fax:
Practice Address - Street 1:974 BRECKENRIDGE LN # 171
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4619
Practice Address - Country:US
Practice Address - Phone:502-694-9432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY261787103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical