Healthcare Provider Details

I. General information

NPI: 1801010939
Provider Name (Legal Business Name): JEFFREY D LEITZEL PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 ADAMS AVE
SCRANTON PA
18503-1604
US

IV. Provider business mailing address

514 MILES AVE
OLYPHANT PA
18447-1351
US

V. Phone/Fax

Practice location:
  • Phone: 570-348-6100
  • Fax: 570-383-6847
Mailing address:
  • Phone: 570-650-6286
  • Fax: 570-383-6847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS015403
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: