Provider Demographics
NPI:1477736346
Name:LELLESS, DESIREE T
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:T
Last Name:LELLESS
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 1:18484 OUTER HWY 18
Mailing Address - Street 2:SUITE 125
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2375
Mailing Address - Country:US
Mailing Address - Phone:760-240-6827
Mailing Address - Fax:760-885-3572
Practice Address - Street 1:18484 OUTER HWY 18
Practice Address - Street 2:SUITE 125
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2375
Practice Address - Country:US
Practice Address - Phone:760-240-6827
Practice Address - Fax:760-885-3572
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-13
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X
CAIMF80409106H00000X
CALMFT 90580106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor