=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831384718
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICK MACLEAMY PSYD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2007
-----------------------------------------------------
Last Update Date | 01/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 755 BAYWOOD DR FL 2
-----------------------------------------------------
City | PETALUMA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94954-5510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-241-3559
-----------------------------------------------------
Fax | 707-772-5209
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 755 BAYWOOD DR FL 2
-----------------------------------------------------
City | PETALUMA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94954-5510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-241-3559
-----------------------------------------------------
Fax | 707-772-5209
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TM1800X
-----------------------------------------------------
Taxonomy Name | Intellectual & Developmental Disabilities Psychologist
-----------------------------------------------------
License Number | PSY22989
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------