Provider Demographics
NPI:1518566462
Name:DE LA ROSA, LEA MARIE (AMFT)
Entity Type:Individual
Prefix:MRS
First Name:LEA
Middle Name:MARIE
Last Name:DE LA ROSA
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12383 MISSISSIPPI DR
Mailing Address - Street 2:
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:91752-1462
Mailing Address - Country:US
Mailing Address - Phone:909-569-7532
Mailing Address - Fax:
Practice Address - Street 1:15740 TURNBERRY ST
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-4903
Practice Address - Country:US
Practice Address - Phone:951-363-8449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA113444106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist