Healthcare Provider Details

I. General information

NPI: 1609309103
Provider Name (Legal Business Name): LELAND VANDENDALE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: LELAND VAN DEN DAELE PHD

II. Dates (important events)

Enumeration Date: 04/11/2017
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

870 MARKET ST STE 1186
SAN FRANCISCO CA
94102-2922
US

IV. Provider business mailing address

4480 FAIRWAY DR
ROHNERT PARK CA
94928-1440
US

V. Phone/Fax

Practice location:
  • Phone: 415-359-4117
  • Fax:
Mailing address:
  • Phone: 415-359-4117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License NumberPSY 9210
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPSY 9210
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY 9210
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 9210
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: