Provider Demographics
NPI:1073244471
Name:DAZO, LESLIE YENEDITH
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:YENEDITH
Last Name:DAZO
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 1:265 SAN JACINTO RIVER RD STE 107
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-4400
Mailing Address - Country:US
Mailing Address - Phone:951-674-9243
Mailing Address - Fax:
Practice Address - Street 1:265 SAN JACINTO RIVER RD
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4419
Practice Address - Country:US
Practice Address - Phone:951-674-9243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-17
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA108963104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker