Provider Demographics
NPI:1811692973
Name:LEAL, CAROLINA
Entity type:Individual
Prefix:
First Name:CAROLINA
Middle Name:
Last Name:LEAL
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 1:5418 INGLEWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-6253
Mailing Address - Country:US
Mailing Address - Phone:310-746-8837
Mailing Address - Fax:
Practice Address - Street 1:5005 TEXAS ST STE 106
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3722
Practice Address - Country:US
Practice Address - Phone:619-330-5670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-30
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst