Provider Demographics
NPI:1538129093
Name:LEIZER, JOSEPH I (PHD)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:I
Last Name:LEIZER
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:PO BOX 5361
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24115-5361
Mailing Address - Country:US
Mailing Address - Phone:276-632-3572
Mailing Address - Fax:276-638-5287
Practice Address - Street 1:1079 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-4506
Practice Address - Country:US
Practice Address - Phone:276-632-3572
Practice Address - Fax:276-638-5287
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-27
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810000740103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA025581OtherANTHEM
VA7728875Medicaid
VA7728875Medicaid