Provider Demographics
NPI:1720315096
Name:LEISHMAN, KRISTEN NICOL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:NICOL
Last Name:LEISHMAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2461 SANTA MONICA BLVD
Mailing Address - Street 2:#730
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2138
Mailing Address - Country:US
Mailing Address - Phone:310-461-8561
Mailing Address - Fax:
Practice Address - Street 1:911 COEUR D'ALENE AVE
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291
Practice Address - Country:US
Practice Address - Phone:310-448-8882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-06
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 390200000X
CAPSY26811103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program