Healthcare Provider Details

I. General information

NPI: 1447461363
Provider Name (Legal Business Name): COURTNEY JEAN LEEDOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 W CHAPMAN AVE STE 101
ORANGE CA
92868-2862
US

IV. Provider business mailing address

P.O. BOX 1533
ORANGE CA
92856-1533
US

V. Phone/Fax

Practice location:
  • Phone: 714-532-6713
  • Fax: 714-223-0663
Mailing address:
  • Phone: 714-532-6713
  • Fax: 714-223-0663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC41709
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: