Provider Demographics
NPI:1265865380
Name:ENTEZAM, LEILA
Entity Type:Individual
Prefix:
First Name:LEILA
Middle Name:
Last Name:ENTEZAM
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 1:26548 MOULTON PKWY STE L
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-6200
Mailing Address - Country:US
Mailing Address - Phone:619-200-7902
Mailing Address - Fax:
Practice Address - Street 1:26548 MOULTON PKWY STE L
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-6200
Practice Address - Country:US
Practice Address - Phone:619-200-7902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist