Provider Demographics
NPI:1164174371
Name:VINCENT, LEANDRA DIANNE
Entity Type:Individual
Prefix:
First Name:LEANDRA
Middle Name:DIANNE
Last Name:VINCENT
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 1:32561 CLOUD CREST CT
Mailing Address - Street 2:
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-8263
Mailing Address - Country:US
Mailing Address - Phone:910-787-3280
Mailing Address - Fax:
Practice Address - Street 1:26720 YNEZ CT
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-4659
Practice Address - Country:US
Practice Address - Phone:951-813-4034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician