Provider Demographics
NPI:1801333489
Name:MUNGUIA, LESLIE ZAMORA
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:ZAMORA
Last Name:MUNGUIA
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 1:12968 FREDERICK ST STE A
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-5229
Mailing Address - Country:US
Mailing Address - Phone:951-208-0150
Mailing Address - Fax:
Practice Address - Street 1:12968 FREDERICK ST STE A
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-5229
Practice Address - Country:US
Practice Address - Phone:951-208-0150
Practice Address - Fax:951-208-0409
Is Sole Proprietor?:No
Enumeration Date:2017-01-20
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA123777106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist