Healthcare Provider Details

I. General information

NPI: 1104202159
Provider Name (Legal Business Name): LEISA KATHLEEN ENSWORTH M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2015
Last Update Date: 07/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7851 WALKER ST STE 206
LA PALMA CA
90623-1746
US

IV. Provider business mailing address

7851 WALKER ST STE 206
LA PALMA CA
90623-1746
US

V. Phone/Fax

Practice location:
  • Phone: 714-523-4327
  • Fax:
Mailing address:
  • Phone: 714-523-4327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAU1155
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: