Provider Demographics
NPI:1508077678
Name:PADILLA, LEONILA REALEZA (TEACHER)
Entity Type:Individual
Prefix:
First Name:LEONILA
Middle Name:REALEZA
Last Name:PADILLA
Suffix:
Gender:F
Credentials:TEACHER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 MARSHALL WAY
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94589-1946
Mailing Address - Country:US
Mailing Address - Phone:707-731-2747
Mailing Address - Fax:707-731-2748
Practice Address - Street 1:11 MARSHALL WAY
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-1946
Practice Address - Country:US
Practice Address - Phone:707-731-2747
Practice Address - Fax:707-731-2748
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC61065FOtherMEDICAL PROVIDER NUMBER