Provider Demographics
NPI:1669964987
Name:GORDON, LESLIE CARDENAS
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:CARDENAS
Last Name:GORDON
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 1:1262 PERSIMMON AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-4979
Mailing Address - Country:US
Mailing Address - Phone:619-368-0771
Mailing Address - Fax:
Practice Address - Street 1:2820 CAMINO DEL RIO S STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3822
Practice Address - Country:US
Practice Address - Phone:619-549-6608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1396085718Medicaid