MEDICARE: DR. LESLIE H LESSENGER PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY16169	CA

General Provider Information

NPI Number	:	1457434110
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LESLIE H LESSENGER PHD

Provider Business Mailing Address
First Line	:	301 GEORGIA ST
Second Line	:	SUITE 306
City	:	VALLEJO
State	:	CA
Zip	:	94590-5946
Country	:	US
Telephone Number	:	707-644-4098
Fax Number	:	707-751-0857

Provider Business Practice Location Address
First Line	:	301 GEORGIA ST
Second Line	:	SUITE 306
City	:	VALLEJO
State	:	CA
Zip	:	94590-5946
Country	:	US
Telephone Number	:	707-644-4098
Fax Number	:	707-751-0857

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	07/08/2007

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