Healthcare Provider Details

I. General information

NPI: 1437831948
Provider Name (Legal Business Name): MI PAZ COUNSELING KENNY AND LESLIE GALLEGOS LCSW PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2023
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11799 SEBASTIAN WAY STE 103
RANCHO CUCAMONGA CA
91730-0708
US

IV. Provider business mailing address

11799 SEBASTIAN WAY STE 103
RANCHO CUCAMONGA CA
91730-0708
US

V. Phone/Fax

Practice location:
  • Phone: 909-810-7209
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: LESLIE ROMERO-GALLEGOS
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 909-810-7209