Healthcare Provider Details

I. General information

NPI: 1679395701
Provider Name (Legal Business Name): JUSTIN LEITER-MCBETH PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2024
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5855 SILVER CREEK VALLEY RD
SAN JOSE CA
95138-1059
US

IV. Provider business mailing address

5855 SILVER CREEK VALLEY RD
SAN JOSE CA
95138-1059
US

V. Phone/Fax

Practice location:
  • Phone: 408-574-9100
  • Fax:
Mailing address:
  • Phone: 408-574-9100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number35451
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number35451
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: