Healthcare Provider Details

I. General information

NPI: 1013668862
Provider Name (Legal Business Name): SANDRA LEON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2022
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 SHADOWRIDGE DR
VISTA CA
92083-7986
US

IV. Provider business mailing address

320 POMELO DR APT 81
VISTA CA
92081-6472
US

V. Phone/Fax

Practice location:
  • Phone: 209-351-4048
  • Fax:
Mailing address:
  • Phone: 209-351-4048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number126091
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number126091
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: