MEDICARE: DR. LELAND VANDENDALE 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	102L00000X	Psychoanalyst	PSY 9210	CA
2	103TA0700X	Adult Development & Aging Psychologist	PSY 9210	CA
3	103TC2200X	Clinical Child & Adolescent Psychologist	PSY 9210	CA
4	103TC0700X	Clinical Psychologist	PSY 9210	CA

General Provider Information

NPI Number	:	1609309103
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LELAND VANDENDALE PHD

Provider Business Mailing Address
First Line	:	4480 FAIRWAY DR
Second Line	:
City	:	ROHNERT PARK
State	:	CA
Zip	:	94928-1440
Country	:	US
Telephone Number	:	415-359-4117
Fax Number	:

Provider Business Practice Location Address
First Line	:	870 MARKET ST STE 1186
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94102-2922
Country	:	US
Telephone Number	:	415-359-4117
Fax Number	:

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

Provider Enumeration Date	:	04/11/2017
Last Update Date	:	03/29/2021

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