Healthcare Provider Details

I. General information

NPI: 1447719190
Provider Name (Legal Business Name): LEAH MARIE PUDDESTER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2019
Last Update Date: 03/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 WOODSTEAD CT STE 420
SPRING TX
77380-3404
US

IV. Provider business mailing address

31233 NEW FOREST PARK LN
SPRING TX
77386-4604
US

V. Phone/Fax

Practice location:
  • Phone: 281-363-4220
  • Fax:
Mailing address:
  • Phone: 713-535-0713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number38109
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: