Provider Demographics
NPI:1629248752
Name:FRY LEONARD, ELISA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ELISA
Middle Name:
Last Name:FRY LEONARD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18831 KILFINAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTER RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91326-1048
Mailing Address - Country:US
Mailing Address - Phone:818-368-6973
Mailing Address - Fax:
Practice Address - Street 1:25000 AVENUE STANFORD
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-1224
Practice Address - Country:US
Practice Address - Phone:818-521-5245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 239971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical