Provider Demographics
NPI:1811459381
Name:DE LEON, JUSTYN (CCC-SLP)
Entity type:Individual
Prefix:
First Name:JUSTYN
Middle Name:
Last Name:DE LEON
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5717 S GRAMERCY PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90062-2546
Mailing Address - Country:US
Mailing Address - Phone:323-302-2516
Mailing Address - Fax:
Practice Address - Street 1:4109 EMERALD ST
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-3105
Practice Address - Country:US
Practice Address - Phone:310-793-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28207235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA28207OtherCA SLP LICENSE