Provider Demographics
NPI:1053073015
Name:LEATH, RHONDA ELISE
Entity Type:Individual
Prefix:
First Name:RHONDA
Middle Name:ELISE
Last Name:LEATH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13552 AVENAL ST APT 59
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-8121
Mailing Address - Country:US
Mailing Address - Phone:442-251-6073
Mailing Address - Fax:
Practice Address - Street 1:1840 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-3235
Practice Address - Country:US
Practice Address - Phone:760-255-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1338760219101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR1338760219OtherCCAPP