Healthcare Provider Details

I. General information

NPI: 1982179941
Provider Name (Legal Business Name): ANGELICA LEYVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2018
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1126 W FOOTHILL BLVD STE 110
UPLAND CA
91786-3786
US

IV. Provider business mailing address

1126 W FOOTHILL BLVD STE 110
UPLAND CA
91786-3786
US

V. Phone/Fax

Practice location:
  • Phone: 909-985-0513
  • Fax:
Mailing address:
  • Phone: 909-985-0513
  • Fax: 909-985-7193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: