Provider Demographics
NPI:1376973412
Name:FROST, LEO (CMT BCSI)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:
Last Name:FROST
Suffix:
Gender:M
Credentials:CMT BCSI
Other - Prefix:
Other - First Name:LEONID
Other - Middle Name:
Other - Last Name:MOROZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:133 BRIDGE ST STE E
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-3366
Mailing Address - Country:US
Mailing Address - Phone:805-457-5729
Mailing Address - Fax:
Practice Address - Street 1:133 BRIDGE ST STE E
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-3366
Practice Address - Country:US
Practice Address - Phone:805-457-5729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-26
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA71881225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist