Provider Demographics
NPI:1477192722
Name:LEDESMA, ROBERTA
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:LEDESMA
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 1:910 E 24TH ST
Mailing Address - Street 2:
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950-7120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2340 E 8TH ST STE H
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2877
Practice Address - Country:US
Practice Address - Phone:619-232-9343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-03
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1370781119101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)