Provider Demographics
NPI:1336912336
Name:GLOVER, LEON ALEXANDER (SAP, ICADC II)
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:ALEXANDER
Last Name:GLOVER
Suffix:
Gender:M
Credentials:SAP, ICADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17177 LA MINA LN
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-9836
Mailing Address - Country:US
Mailing Address - Phone:951-943-2051
Mailing Address - Fax:
Practice Address - Street 1:17177 LA MINA LN
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92570-9836
Practice Address - Country:US
Practice Address - Phone:951-943-2051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARA8421016101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)