Provider Demographics
NPI:1932747763
Name:ALTIDOR, LEODOR (LGPC)
Entity Type:Individual
Prefix:
First Name:LEODOR
Middle Name:
Last Name:ALTIDOR
Suffix:
Gender:M
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7207 BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740-3269
Mailing Address - Country:US
Mailing Address - Phone:301-615-8802
Mailing Address - Fax:
Practice Address - Street 1:7207 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-3269
Practice Address - Country:US
Practice Address - Phone:301-615-8802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-11
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP8988101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLGP8988OtherMARYLAND BOARD OF COUNSELING