Provider Demographics
NPI:1720099203
Name:LEYSE, SALLY JO (LCPC)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:JO
Last Name:LEYSE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:MS
Other - First Name:SALLY
Other - Middle Name:JO
Other - Last Name:LEYSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCPC
Mailing Address - Street 1:601A PIONEER MOUNTAIN LOOP
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-6557
Mailing Address - Country:US
Mailing Address - Phone:208-420-5902
Mailing Address - Fax:
Practice Address - Street 1:601A PIONEER MOUNTAIN LOOP
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-6557
Practice Address - Country:US
Practice Address - Phone:208-420-5902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-215101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010017683OtherBLUE SHIELD
ID12249540OtherCAQH
IDQ215-6OtherBLUE CROSS