Healthcare Provider Details

I. General information

NPI: 1467110544
Provider Name (Legal Business Name): LEANN GLASS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2021
Last Update Date: 06/29/2024
Certification Date: 06/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 CALLE AMANECER
SAN CLEMENTE CA
92673-6214
US

IV. Provider business mailing address

22482 ALMA ALDEA APT 190
RANCHO SANTA MARGARITA CA
92688-2835
US

V. Phone/Fax

Practice location:
  • Phone: 949-498-5100
  • Fax:
Mailing address:
  • Phone: 949-677-5811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-73936
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-195339
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: