1780873133 NPI number — DR. LESLIE GAIL MAXSON PH.D., PSY.D

Table of content: DR. LESLIE GAIL MAXSON PH.D., PSY.D (NPI 1780873133)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780873133 NPI number — DR. LESLIE GAIL MAXSON PH.D., PSY.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAXSON
Provider First Name:
LESLIE
Provider Middle Name:
GAIL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D., PSY.D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MAXSON
Provider Other First Name:
LESLIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PH.D., PSY.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1780873133
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
138 N BRAND BLVD
Provider Second Line Business Mailing Address:
SUITE #300
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91203-4614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-956-8240
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
138 N BRAND BLVD
Provider Second Line Business Practice Location Address:
SUITE #300
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91203-4614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-956-8240
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY9843 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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