Provider Demographics
NPI:1659030229
Name:ROA-GUTIERREZ, LEAH T
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:T
Last Name:ROA-GUTIERREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10935 SUMAC CT
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92337-6841
Mailing Address - Country:US
Mailing Address - Phone:909-222-0648
Mailing Address - Fax:
Practice Address - Street 1:1091 N BATAVIA ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-5548
Practice Address - Country:US
Practice Address - Phone:909-969-1405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator