Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | PSY17791 | CA |
Y | 103TC0700X | Clinical Psychologist | PSY17791 | CA |
NPI | 1013090778 |
---|---|
Provider Name | Leonard Simon |
First Address | Los Angeles, CA 90004-3720 |
Second Address | San Diego, CA 92123-1658 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/10/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
PSY177910 | (05) | CA |