Active NPI
Broderick Leaks, PHD
- Clinical Psychologist
- Pasadena, CA
National Provider Identifier
1649565102
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- PSY 24273
- Practice address
- 595 E Colorado Blvd
Suite 708
Pasadena, CA 91101-2039 - Phone
- (626) 421-8956
- NPI assigned
- Jun 13, 2011
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | PSY 24273 | CA | Primary |
Addresses
Primary practice location
595 E Colorado Blvd
Suite 708
Pasadena, CA 91101-2039
Mailing address
595 E Colorado Blvd
Suite 708
Pasadena, CA 91101-2039
Phone (626) 421-8956
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PSY 24273 | CA | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1307923200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1307923200000",
"number": "1649565102",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "595 E COLORADO BLVD",
"address_2": "SUITE 708",
"city": "PASADENA",
"state": "CA",
"postal_code": "911012039",
"telephone_number": "626-421-8956"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "595 E COLORADO BLVD",
"address_2": "SUITE 708",
"city": "PASADENA",
"state": "CA",
"postal_code": "911012039",
"telephone_number": "626-421-8956"
}
],
"practiceLocations": [],
"basic": {
"last_name": "LEAKS",
"first_name": "BRODERICK",
"name_prefix": "Dr.",
"credential": "PHD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2011-06-13",
"last_updated": "2011-06-13",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "CA",
"license": "PSY 24273",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Pasadena, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 13, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.