Healthcare Provider Details

I. General information

NPI: 1235769100
Provider Name (Legal Business Name): MIRANDA RENEE LEON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIRANDA RENEE BARNES LCSW

II. Dates (important events)

Enumeration Date: 01/20/2020
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 W BROADWAY STE 400
SAN DIEGO CA
92101-3554
US

IV. Provider business mailing address

2283 KYLA CT
SAN BERNARDINO CA
92410-1305
US

V. Phone/Fax

Practice location:
  • Phone: 866-478-3978
  • Fax:
Mailing address:
  • Phone: 951-275-4944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW124658
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: