Provider Demographics
NPI:1265686612
Name:LEISEROWITZ, GINA SUSAN (MED)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:SUSAN
Last Name:LEISEROWITZ
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81-711 CA HIWAY 111
Mailing Address - Street 2:SUITE 101
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201
Mailing Address - Country:US
Mailing Address - Phone:760-347-2398
Mailing Address - Fax:
Practice Address - Street 1:81-711 CA HIWAY 111
Practice Address - Street 2:SUITE 101
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-9785
Practice Address - Country:US
Practice Address - Phone:760-347-2398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-12
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19251101YM0800X
CA48090106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health