Provider Demographics
NPI:1831654375
Name:VAN PELT, LEAF
Entity Type:Individual
Prefix:
First Name:LEAF
Middle Name:
Last Name:VAN PELT
Suffix:
Gender:M
Credentials:
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 3940
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:CA
Mailing Address - Zip Code:95971-3940
Mailing Address - Country:US
Mailing Address - Phone:530-283-3330
Mailing Address - Fax:
Practice Address - Street 1:350 MAIN ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:CA
Practice Address - Zip Code:95971-9375
Practice Address - Country:US
Practice Address - Phone:530-283-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator