Healthcare Provider Details

I. General information

NPI: 1437471190
Provider Name (Legal Business Name): LEYLA T BRUSATORI PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2010
Last Update Date: 09/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1812 W KETTLEMAN LN STE 3
LODI CA
95242-4209
US

IV. Provider business mailing address

1812 W KETTLEMAN LN STE 3
LODI CA
95242-4209
US

V. Phone/Fax

Practice location:
  • Phone: 707-225-2317
  • Fax: 209-593-3000
Mailing address:
  • Phone: 707-225-2317
  • Fax: 209-593-3000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY 23080
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberPSY 23080
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: