Healthcare Provider Details

I. General information

NPI: 1316004914
Provider Name (Legal Business Name): LESLIE JEAN BENNETT THAYER PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 04/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8355 LA MESA BLVD
LA MESA CA
91942-9249
US

IV. Provider business mailing address

PO BOX 880914
SAN DIEGO CA
92168-0914
US

V. Phone/Fax

Practice location:
  • Phone: 619-354-4423
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number27726
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: