Provider Demographics
NPI:1174049613
Name:LEDERGERBER, KANDACE COLLEEN
Entity type:Individual
Prefix:MRS
First Name:KANDACE
Middle Name:COLLEEN
Last Name:LEDERGERBER
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KANDACE
Other - Middle Name:COLLEEN
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1515 MICHELIN CT
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549
Mailing Address - Country:US
Mailing Address - Phone:813-949-8946
Mailing Address - Fax:813-948-1578
Practice Address - Street 1:2425 CHATLIN RD
Practice Address - Street 2:
Practice Address - City:HOLIDAY
Practice Address - State:FL
Practice Address - Zip Code:34691
Practice Address - Country:US
Practice Address - Phone:813-738-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-16
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2846675Medicaid