Provider Demographics
NPI:1629499603
Name:LEONARD, KATIE PATRICIA (BA)
Entity Type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:PATRICIA
Last Name:LEONARD
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 N AURORA ST STE 6
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-2276
Mailing Address - Country:US
Mailing Address - Phone:209-496-6992
Mailing Address - Fax:
Practice Address - Street 1:2617 CORAL OAK DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-9547
Practice Address - Country:US
Practice Address - Phone:209-496-6992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-18
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1711419111101YA0400X
CAAMFT108415101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)