Provider Demographics
NPI:1326673104
Name:LEON, ROQUE
Entity Type:Individual
Prefix:
First Name:ROQUE
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 1:576 S 5TH ST APT 18
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-5649
Mailing Address - Country:US
Mailing Address - Phone:559-310-2661
Mailing Address - Fax:
Practice Address - Street 1:576 S 5TH ST APT 18
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-5649
Practice Address - Country:US
Practice Address - Phone:559-310-2661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF1886415103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst