Healthcare Provider Details

I. General information

NPI: 1740901230
Provider Name (Legal Business Name): DELEON DEVAUGHN LPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2022
Last Update Date: 09/05/2022
Certification Date: 09/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 E HOUSTON ST
COALINGA CA
93210-2614
US

IV. Provider business mailing address

232 E HOUSTON ST
COALINGA CA
93210-2614
US

V. Phone/Fax

Practice location:
  • Phone: 626-644-5665
  • Fax:
Mailing address:
  • Phone: 626-644-5665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number41083
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: