Provider Demographics
NPI:1558453589
Name:O'CONNELL, LESLIE ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:ANN
Last Name:O'CONNELL
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 653
Mailing Address - Street 2:
Mailing Address - City:ROSS
Mailing Address - State:CA
Mailing Address - Zip Code:94957-0653
Mailing Address - Country:US
Mailing Address - Phone:415-459-9939
Mailing Address - Fax:
Practice Address - Street 1:600 5TH AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3348
Practice Address - Country:US
Practice Address - Phone:415-419-3645
Practice Address - Fax:415-491-7958
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 18629103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ER197AOtherMEDICARE PTAN