Healthcare Provider Details

I. General information

NPI: 1417478801
Provider Name (Legal Business Name): CORRIDOR COUNSELING, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2017
Last Update Date: 07/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4403 1ST AVE SE
CEDAR RAPIDS IA
52402-3200
US

IV. Provider business mailing address

PO BOX 1561
CEDAR RAPIDS IA
52406-1561
US

V. Phone/Fax

Practice location:
  • Phone: 319-270-0019
  • Fax: 319-294-7032
Mailing address:
  • Phone: 319-270-0019
  • Fax: 319-294-7032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number000435
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1154713964
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name: MR. JOHN RYAN LEEFERS
Title or Position: THERAPIST/OWNER & SOLE MEMBER
Credential: LMFT
Phone: 319-270-0019