Provider Demographics
NPI:1497829436
Name:LEATHERDALE, KIMBERLY N (ATR, LPC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:N
Last Name:LEATHERDALE
Suffix:
Gender:F
Credentials:ATR, LPC
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 87
Mailing Address - Street 2:
Mailing Address - City:PLUCKEMIN
Mailing Address - State:NJ
Mailing Address - Zip Code:07978-0087
Mailing Address - Country:US
Mailing Address - Phone:908-256-4779
Mailing Address - Fax:
Practice Address - Street 1:254 ROUTES 202 206
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:PLUCKEMIN
Practice Address - State:NJ
Practice Address - Zip Code:07978
Practice Address - Country:US
Practice Address - Phone:908-256-4779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00043700101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health