Healthcare Provider Details

I. General information

NPI: 1194887836
Provider Name (Legal Business Name): LEO R. ESPINOSA P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11080 W OLYMPIC BLVD
LOS ANGELES CA
90064-1937
US

IV. Provider business mailing address

812 W HUNTINGTON DR APT 6
ARCADIA CA
91007-6619
US

V. Phone/Fax

Practice location:
  • Phone: 310-966-6610
  • Fax:
Mailing address:
  • Phone: 310-966-6610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT31641
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: