MEDICARE: MR. LERON SAMUEL RIBEIRO-WEST ACSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	119013	CA
2	390200000X	Student in an Organized Health Care Education/Training Program	119013	CA

General Provider Information

NPI Number	:	1437703667
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LERON SAMUEL RIBEIRO-WEST ACSW

Provider Business Mailing Address
First Line	:	PO BOX 110
Second Line	:
City	:	BIG BEAR LAKE
State	:	CA
Zip	:	92315-0110
Country	:	US
Telephone Number	:	402-904-2162
Fax Number	:

Provider Business Practice Location Address
First Line	:	PO BOX 1649
Second Line	:
City	:	BIG BEAR LAKE
State	:	CA
Zip	:	92315-1649
Country	:	US
Telephone Number	:	909-878-8246
Fax Number	:	909-878-2494

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2019
Last Update Date	:	12/05/2025

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