Provider Demographics
NPI:1013095744
Name:LEEDS, ANDREW M (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:M
Last Name:LEEDS
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 1:1049 4TH ST STE G
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4345
Mailing Address - Country:US
Mailing Address - Phone:707-579-9457
Mailing Address - Fax:707-579-4515
Practice Address - Street 1:1049 4TH ST STE G
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4345
Practice Address - Country:US
Practice Address - Phone:707-579-9457
Practice Address - Fax:707-579-4515
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10471103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL104711Medicare ID - Type Unspecified