Provider Demographics
NPI:1336774678
Name:GRIFFIN, LECLETUS JR
Entity Type:Individual
Prefix:MR
First Name:LECLETUS
Middle Name:
Last Name:GRIFFIN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 N. CALIFRONIA STREET
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202
Mailing Address - Country:US
Mailing Address - Phone:209-468-8779
Mailing Address - Fax:
Practice Address - Street 1:1212 N. CALIFRONIA STREET
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202
Practice Address - Country:US
Practice Address - Phone:209-468-8779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC7490101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor