Provider Demographics
NPI:1790404382
Name:LEON, CARLOS ANDRES (SUDCC II)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:ANDRES
Last Name:LEON
Suffix:
Gender:M
Credentials:SUDCC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1565 PEMBROKE WAY
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:CA
Mailing Address - Zip Code:95620-2467
Mailing Address - Country:US
Mailing Address - Phone:707-913-5813
Mailing Address - Fax:
Practice Address - Street 1:4820 BUSINESS CENTER DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-1696
Practice Address - Country:US
Practice Address - Phone:707-224-8266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-25
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7289101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)