Healthcare Provider Details

I. General information

NPI: 1104712173
Provider Name (Legal Business Name): CARLOS JAVIER LEDEZMA GONZALEZ ASW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 BIRCH ST STE 3000
NEWPORT BEACH CA
92660-2140
US

IV. Provider business mailing address

212 S KRAEMER BLVD UNIT 1403
PLACENTIA CA
92870-6103
US

V. Phone/Fax

Practice location:
  • Phone: 877-421-1711
  • Fax: 949-376-5913
Mailing address:
  • Phone: 714-386-0746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW130626
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW130626
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: