Provider Demographics
NPI:1336226083
Name:LEONARD, JOHN E (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:LEONARD
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 1:2659 PORTAGE BAY E
Mailing Address - Street 2:SUITE 204
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-3050
Mailing Address - Country:US
Mailing Address - Phone:530-756-6438
Mailing Address - Fax:530-419-0774
Practice Address - Street 1:2659 PORTAGE BAY E
Practice Address - Street 2:SUITE 204
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-3050
Practice Address - Country:US
Practice Address - Phone:530-756-6438
Practice Address - Fax:530-419-0774
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12821103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA68-0321221OtherEIN
CAOPL128210Medicare ID - Type UnspecifiedMEDICARE ID#