Provider Demographics
NPI:1740332139
Name:LEERER, C GIRVANI (PHD)
Entity type:Individual
Prefix:DR
First Name:C
Middle Name:GIRVANI
Last Name:LEERER
Suffix:
Gender:F
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:PO BOX 2956
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94702-0956
Mailing Address - Country:US
Mailing Address - Phone:510-649-9624
Mailing Address - Fax:
Practice Address - Street 1:3637 GRAND AVE
Practice Address - Street 2:SUITE G
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-2029
Practice Address - Country:US
Practice Address - Phone:510-649-9624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2015-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7289103TC1900X
CA24631103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0596175Medicaid
MA0596175Medicaid
MA1063559Medicare UPIN
MA3157-01Medicare UPIN
MAW05769Medicare UPIN