Healthcare Provider Details

I. General information

NPI: 1215012729
Provider Name (Legal Business Name): LESLIE M SIMON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 10/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 LINCOLN AVE SUITE 306
SAN RAFAEL CA
94901-2120
US

IV. Provider business mailing address

PO BOX 1209
MILL VALLEY CA
94942-1209
US

V. Phone/Fax

Practice location:
  • Phone: 415-460-9072
  • Fax: 415-444-5575
Mailing address:
  • Phone: 415-460-9072
  • Fax: 415-444-5575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY 14378
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 14378
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY 14378
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: