Provider Demographics
NPI:1609309103
Name:VANDENDALE, LELAND (PHD)
Entity Type:Individual
Prefix:DR
First Name:LELAND
Middle Name:
Last Name:VANDENDALE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:LELAND
Other - Middle Name:
Other - Last Name:VAN DEN DAELE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:4480 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-1440
Mailing Address - Country:US
Mailing Address - Phone:415-359-4117
Mailing Address - Fax:
Practice Address - Street 1:870 MARKET ST STE 1186
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-2922
Practice Address - Country:US
Practice Address - Phone:415-359-4117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-11
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 9210102L00000X, 103TA0700X, 103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent