Healthcare Provider Details

I. General information

NPI: 1154152528
Provider Name (Legal Business Name): AGNES DIANA LEONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2024
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

482 W SAN CARLOS ST
SAN JOSE CA
95110-2627
US

IV. Provider business mailing address

4850 UNION AVE
SAN JOSE CA
95124-5156
US

V. Phone/Fax

Practice location:
  • Phone: 669-254-5078
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPCC19994
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: