Provider Demographics
NPI:1417372897
Name:LEOS-GOMEZ, ANNEMARIE
Entity Type:Individual
Prefix:
First Name:ANNEMARIE
Middle Name:
Last Name:LEOS-GOMEZ
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 1:1266 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-6034
Mailing Address - Country:US
Mailing Address - Phone:323-691-6321
Mailing Address - Fax:
Practice Address - Street 1:1125 W 6TH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1833
Practice Address - Country:US
Practice Address - Phone:213-202-3970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-21
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF79073106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist