Basic Information
| Provider Information | |||||||||
| NPI: | 1609081025 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEADBETTER | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEADBETTER EISELE | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PH.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4371 YORKTOWN DR | ||||||||
| Address2: | |||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551233030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514521028 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3333 UNIVERSITY AVE SE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554143325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123319413 | ||||||||
| FaxNumber: | 6127285301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | LP4480 | MN | X | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TC0700X | LP4480 | MN | X | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | LP4480 | MN | X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.