Healthcare Provider Details

I. General information

NPI: 1548838568
Provider Name (Legal Business Name): LEONIDAS EDMUNDO CARRASCO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2021
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 FILBERT ST
OAKLAND CA
94607-2890
US

IV. Provider business mailing address

3979 ALHAMBRA AVE APT 211
MARTINEZ CA
94553-3836
US

V. Phone/Fax

Practice location:
  • Phone: 510-663-9092
  • Fax:
Mailing address:
  • Phone: 510-621-4566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: