Provider Demographics
NPI:1083491013
Name:DE LEON, MOISES ROBERTO
Entity type:Individual
Prefix:
First Name:MOISES
Middle Name:ROBERTO
Last Name:DE LEON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9054 CLENDENEN WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-5512
Mailing Address - Country:US
Mailing Address - Phone:805-668-1249
Mailing Address - Fax:
Practice Address - Street 1:6833 STOCKTON BLVD STE 485
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2376
Practice Address - Country:US
Practice Address - Phone:916-942-9060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-12
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT152392106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist