Healthcare Provider Details

I. General information

NPI: 1447789037
Provider Name (Legal Business Name): LESLIE BOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6711 ARLINGTON AVE STE B
RIVERSIDE CA
92504-1966
US

IV. Provider business mailing address

26132 CLYDESDALE LN
MORENO VALLEY CA
92555-3308
US

V. Phone/Fax

Practice location:
  • Phone: 951-352-4964
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number109208
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: