Healthcare Provider Details

I. General information

NPI: 1275997579
Provider Name (Legal Business Name): DR. JUSTIN LEAZENBY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 29TH ST # 512
SAN FRANCISCO CA
94110-4929
US

IV. Provider business mailing address

60 29TH ST # 512
SAN FRANCISCO CA
94110-4929
US

V. Phone/Fax

Practice location:
  • Phone: 916-314-3264
  • Fax:
Mailing address:
  • Phone: 916-314-3264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY27882
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: