Provider Demographics
NPI:1437471190
Name:BRUSATORI, LEYLA T (PHD)
Entity Type:Individual
Prefix:DR
First Name:LEYLA
Middle Name:T
Last Name:BRUSATORI
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 1:1812 W KETTLEMAN LN STE 3
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-4209
Mailing Address - Country:US
Mailing Address - Phone:707-225-2317
Mailing Address - Fax:209-593-3000
Practice Address - Street 1:1812 W KETTLEMAN LN STE 3
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-4209
Practice Address - Country:US
Practice Address - Phone:707-225-2317
Practice Address - Fax:209-593-3000
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-23
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 23080103TF0000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9940639Medicaid