Provider Demographics
NPI:1609359256
Name:EZETA, LEOPOLDO
Entity Type:Individual
Prefix:
First Name:LEOPOLDO
Middle Name:
Last Name:EZETA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:865 3RD AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-1300
Mailing Address - Country:US
Mailing Address - Phone:619-271-7992
Mailing Address - Fax:
Practice Address - Street 1:865 3RD AVE STE 112
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-1300
Practice Address - Country:US
Practice Address - Phone:619-271-7992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor