Provider Demographics
NPI:1477964567
Name:LEITHEISER, ANDREA MARIE (MA, PHD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:MARIE
Last Name:LEITHEISER
Suffix:
Gender:F
Credentials:MA, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 217922
Mailing Address - Street 2:
Mailing Address - City:BARRIGADA
Mailing Address - State:GU
Mailing Address - Zip Code:96921-6957
Mailing Address - Country:US
Mailing Address - Phone:671-688-7712
Mailing Address - Fax:671-637-5550
Practice Address - Street 1:674 HARMON LOOP RD STE 214
Practice Address - Street 2:
Practice Address - City:DEDEDO
Practice Address - State:GU
Practice Address - Zip Code:96929-6535
Practice Address - Country:US
Practice Address - Phone:671-487-7747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-12
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL001257103TB0200X
GUCP000026103TC0700X
NM0942103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral