Provider Demographics
NPI:1417584475
Name:DE LEON, ANTOINETTE
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:DE LEON
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:PO BOX 261054
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91426-1054
Mailing Address - Country:US
Mailing Address - Phone:818-314-1329
Mailing Address - Fax:
Practice Address - Street 1:16060 VENTURA BLVD UNIT 110
Practice Address - Street 2:PMB 1012
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436
Practice Address - Country:US
Practice Address - Phone:818-314-1329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87288106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist