Provider Demographics
NPI:1831351840
Name:EKSTROM, LEANNE MARIE
Entity type:Individual
Prefix:
First Name:LEANNE
Middle Name:MARIE
Last Name:EKSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LEANNE
Other - Middle Name:M
Other - Last Name:STANLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:488 UNIVERSITY AVE APT 416
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94301-1837
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2100 NAPA VALLEJO HWY
Practice Address - Street 2:DEPARTMENT OF STATE HOSPITALS
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-6234
Practice Address - Country:US
Practice Address - Phone:916-651-8906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA26133103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program