Basic Information
| Provider Information | |||||||||
| NPI: | 1497319024 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRIDER | ||||||||
| FirstName: | LEONARD | ||||||||
| MiddleName: | GREGORY | ||||||||
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| Credential: | CSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30324 BLUE HERON ST | ||||||||
| Address2: | |||||||||
| City: | DENHAM SPRINGS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707261791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252813749 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9420 LINDALE AVE | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708154161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2254423540 | ||||||||
| FaxNumber: | 2254423546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2019 | ||||||||
| LastUpdateDate: | 04/29/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.