Provider Demographics
NPI:1164645891
Name:LEEDS, JEREMY (PHD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:LEEDS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 W END AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-5708
Mailing Address - Country:US
Mailing Address - Phone:212-724-3035
Mailing Address - Fax:914-693-2981
Practice Address - Street 1:420 W END AVE
Practice Address - Street 2:SUITE A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-5708
Practice Address - Country:US
Practice Address - Phone:212-724-3035
Practice Address - Fax:914-693-2981
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010043103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist