Basic Information
Provider Information | |||||||||
NPI: | 1831150457 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEASE | ||||||||
FirstName: | CYNTHIA | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1970 ROANOKE BLVD | ||||||||
Address2: |   | ||||||||
City: | SALEM | ||||||||
State: | VA | ||||||||
PostalCode: | 241536404 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5409822463 | ||||||||
FaxNumber: | 5402241957 | ||||||||
Practice Location | |||||||||
Address1: | 1970 ROANOKE BLVD | ||||||||
Address2: |   | ||||||||
City: | SALEM | ||||||||
State: | VA | ||||||||
PostalCode: | 241536404 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5409822463 | ||||||||
FaxNumber: | 5402241957 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/31/2006 | ||||||||
LastUpdateDate: | 05/19/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 0810002492 | VA | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
ID | Type | State | Issuer | Description | 7708084 | 05 | VA |   | MEDICAID | 39373 | 01 |   | ANTHEM BCBS | OTHER | 087373 | 01 |   | SENTARA | OTHER | 280449 | 01 |   | MAGELLAN | OTHER | 250254 | 01 |   | MAMSI | OTHER | 253567 | 01 |   | VALUE OPTIONS | OTHER |