Provider Demographics
NPI:1205144706
Name:MELARA, LESLIE
Entity type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:
Last Name:MELARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:ANDERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2080 S E ST FL 1
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-2773
Mailing Address - Country:US
Mailing Address - Phone:909-388-9191
Mailing Address - Fax:909-388-9195
Practice Address - Street 1:2080 S E ST FL 1
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-2773
Practice Address - Country:US
Practice Address - Phone:909-388-9191
Practice Address - Fax:909-388-9195
Is Sole Proprietor?:No
Enumeration Date:2010-09-17
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34207167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician