Healthcare Provider Details

I. General information

NPI: 1336657113
Provider Name (Legal Business Name): LEROY HARDEN JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2018
Last Update Date: 01/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3845 AVOCADO SCHOOL RD
LA MESA CA
91941-7319
US

IV. Provider business mailing address

3027 CHIPWOOD CT
SPRING VALLEY CA
91978-1966
US

V. Phone/Fax

Practice location:
  • Phone: 619-588-3653
  • Fax:
Mailing address:
  • Phone: 619-779-2872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: