Provider Demographics
NPI:1912575622
Name:ELIZALDE, LESLIE (AMFT)
Entity Type:Individual
Prefix:MISS
First Name:LESLIE
Middle Name:
Last Name:ELIZALDE
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22870 GIANT FIR PL
Mailing Address - Street 2:
Mailing Address - City:CANYON LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92587-7806
Mailing Address - Country:US
Mailing Address - Phone:951-805-6972
Mailing Address - Fax:
Practice Address - Street 1:31946 MISSION TRL STE B
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4539
Practice Address - Country:US
Practice Address - Phone:951-245-7663
Practice Address - Fax:951-245-7717
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT125401106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist