Provider Demographics
NPI:1831770874
Name:LEON, LARAINE LEON M
Entity type:Individual
Prefix:
First Name:LARAINE LEON
Middle Name:M
Last Name:LEON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LARAINE
Other - Middle Name:
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:18726 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-3813
Mailing Address - Country:US
Mailing Address - Phone:310-856-2494
Mailing Address - Fax:
Practice Address - Street 1:1149 W 190TH ST STE 2200
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4344
Practice Address - Country:US
Practice Address - Phone:855-568-2494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00014865106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician