Healthcare Provider Details

I. General information

NPI: 1205758471
Provider Name (Legal Business Name): LOTHLORIEN HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11835 CARMEL MOUNTAIN RD STE 1304-274
SAN DIEGO CA
92128-4609
US

IV. Provider business mailing address

11835 CARMEL MOUNTAIN RD STE 1304-274
SAN DIEGO CA
92128-4609
US

V. Phone/Fax

Practice location:
  • Phone: 858-218-5492
  • 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 State

VIII. Authorized Official

Name: GLENNIE LESHEN
Title or Position: OWNER
Credential: MD
Phone: 858-218-5492