Provider Demographics
NPI:1457479974
Name:MANZELLA, LEONARD STEPHAN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:LEONARD
Middle Name:STEPHAN
Last Name:MANZELLA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11573 LOS OSOS VALLEY RD STE D
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-6461
Mailing Address - Country:US
Mailing Address - Phone:805-541-1434
Mailing Address - Fax:805-473-4750
Practice Address - Street 1:11573 LOS OSOS VALLEY RD STE D
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-6461
Practice Address - Country:US
Practice Address - Phone:805-541-1434
Practice Address - Fax:805-473-4750
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS158981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCS15898OtherPROFESSIONAL LICENSE NUMB