Provider Demographics
NPI:1811176662
Name:LEEPER, ERICIA LYNN (PSYD)
Entity type:Individual
Prefix:DR
First Name:ERICIA
Middle Name:LYNN
Last Name:LEEPER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 CENTER ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-2669
Mailing Address - Country:US
Mailing Address - Phone:573-690-8669
Mailing Address - Fax:573-635-5383
Practice Address - Street 1:2600 CENTER ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2669
Practice Address - Country:US
Practice Address - Phone:573-690-8669
Practice Address - Fax:573-635-5383
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-29
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005038107103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490703501Medicaid