Provider Demographics
NPI:1124577606
Name:LEON, OCTAVIO
Entity Type:Individual
Prefix:
First Name:OCTAVIO
Middle Name:
Last Name:LEON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 436
Mailing Address - Street 2:
Mailing Address - City:BUTTONWILLOW
Mailing Address - State:CA
Mailing Address - Zip Code:93206-0436
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1831 RIDGE RD
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93305-4119
Practice Address - Country:US
Practice Address - Phone:661-868-4300
Practice Address - Fax:661-868-7492
Is Sole Proprietor?:No
Enumeration Date:2016-09-26
Last Update Date:2023-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA67313104100000X
CA1048311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker