Provider Demographics
NPI:1336244631
Name:LEAF, LEIF ERIC (PHD)
Entity Type:Individual
Prefix:
First Name:LEIF
Middle Name:ERIC
Last Name:LEAF
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:ERIC
Other - Middle Name:LEIF
Other - Last Name:LEAF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:13829 HARBOR DR
Mailing Address - Street 2:
Mailing Address - City:BONNER SPRINGS
Mailing Address - State:KS
Mailing Address - Zip Code:66012
Mailing Address - Country:US
Mailing Address - Phone:913-441-1640
Mailing Address - Fax:
Practice Address - Street 1:3515 S 4TH ST
Practice Address - Street 2:PROFESSIONAL ASSOCIATION
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048
Practice Address - Country:US
Practice Address - Phone:913-651-8415
Practice Address - Fax:913-772-8580
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS701103T00000X
MO01356103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS119716OtherBCBS OF KANSAS
2094031OtherCIGNA
KS24103022OtherBCBS OF KC KS
004517OtherBCBS OF KANSAS GROUP
5240235OtherAETNA
5240235OtherAETNA
KSR107502Medicare ID - Type UnspecifiedMEDICARE KANSAS
119890Medicare ID - Type Unspecified
KS24103022OtherBCBS OF KC KS