Provider Demographics
NPI:1700637535
Name:FOX, LEESA AVOCADO (CMT)
Entity Type:Individual
Prefix:
First Name:LEESA
Middle Name:AVOCADO
Last Name:FOX
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5425 SNYDER LN APT 113
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-2940
Mailing Address - Country:US
Mailing Address - Phone:408-464-4359
Mailing Address - Fax:
Practice Address - Street 1:5425 SNYDER LN APT 113
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-2940
Practice Address - Country:US
Practice Address - Phone:408-464-4359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-29
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6513225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist