Provider Demographics
NPI:1013090778
Name:SIMON, LEONARD (PHD)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:
Last Name:SIMON
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 1:157 NORTH LUCERNE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-3720
Mailing Address - Country:US
Mailing Address - Phone:310-963-0160
Mailing Address - Fax:323-461-0311
Practice Address - Street 1:4715 VIEWRIDGE AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1658
Practice Address - Country:US
Practice Address - Phone:800-257-8715
Practice Address - Fax:800-819-1655
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17791103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY177910Medicaid
CAWCP17791AMedicare ID - Type Unspecified