MEDICARE: LEANNE SELF PSY.D.

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	PSY31930	CA

General Provider Information

NPI Number	:	1669741815
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEANNE SELF PSY.D.

Provider Business Mailing Address
First Line	:	1026 W EL NORTE PKWY # 48
Second Line	:
City	:	ESCONDIDO
State	:	CA
Zip	:	92026-3341
Country	:	US
Telephone Number	:	619-395-2885
Fax Number	:	619-393-0390

Provider Business Practice Location Address
First Line	:	201 E GRAND AVE STE 2A
Second Line	:
City	:	ESCONDIDO
State	:	CA
Zip	:	92025-2818
Country	:	US
Telephone Number	:	619-395-2885
Fax Number	:	619-393-0390

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

Provider Enumeration Date	:	12/16/2011
Last Update Date	:	03/30/2023

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