Provider Demographics
NPI:1811543101
Name:NUNEZ, LESLIE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:NUNEZ
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 1:5316 ATLANTIC BLVD APT D
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90270-2462
Mailing Address - Country:US
Mailing Address - Phone:818-788-1003
Mailing Address - Fax:818-788-1135
Practice Address - Street 1:16500 VENTURA BLVD STE 414
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-5050
Practice Address - Country:US
Practice Address - Phone:818-788-1003
Practice Address - Fax:818-788-1135
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA954482700Medicaid