Basic Information
| Provider Information | |||||||||
| NPI: | 1013985639 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEROY | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12425 W BELL RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SURPRISE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853789002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233747774 | ||||||||
| FaxNumber: | 6232401110 | ||||||||
| Practice Location | |||||||||
| Address1: | 12425 W BELL RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SURPRISE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853789006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233747774 | ||||||||
| FaxNumber: | 6232401110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 01/18/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 1766 | AZ | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 066672 | 05 | AZ | MEDICAID |