Provider Demographics
NPI:1801399175
Name:LEEDER, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:LEEDER
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:MATTHEW
Other - Middle Name:
Other - Last Name:LEEDER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5432 RATTLESNAKE HAMMOCK RD
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34113-7454
Mailing Address - Country:US
Mailing Address - Phone:239-316-7656
Mailing Address - Fax:
Practice Address - Street 1:5432 RATTLESNAKE HAMMOCK RD
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34113-7454
Practice Address - Country:US
Practice Address - Phone:239-784-4989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021860600Medicaid