Provider Demographics
NPI:1215012729
Name:SIMON, LESLIE M (PHD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:M
Last Name:SIMON
Suffix:
Gender:F
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:PO BOX 1209
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94942-1209
Mailing Address - Country:US
Mailing Address - Phone:415-460-9072
Mailing Address - Fax:415-444-5575
Practice Address - Street 1:1330 LINCOLN AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2120
Practice Address - Country:US
Practice Address - Phone:415-460-9072
Practice Address - Fax:415-444-5575
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 14378103G00000X, 103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent