Provider Demographics
NPI:1760686372
Name:SUDDARTH, LEAH MARIE (LCPC)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:MARIE
Last Name:SUDDARTH
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2589 S FIVE MILE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-2325
Mailing Address - Country:US
Mailing Address - Phone:208-908-6320
Mailing Address - Fax:208-908-6404
Practice Address - Street 1:2589 S FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-2325
Practice Address - Country:US
Practice Address - Phone:208-908-6320
Practice Address - Fax:208-908-6404
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-7441101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health