Provider Demographics
NPI:1194887836
Name:ESPINOSA, LEO R (PT)
Entity type:Individual
Prefix:
First Name:LEO
Middle Name:R
Last Name:ESPINOSA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 W HUNTINGTON DR APT 6
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-6619
Mailing Address - Country:US
Mailing Address - Phone:310-966-6610
Mailing Address - Fax:
Practice Address - Street 1:11080 W OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1937
Practice Address - Country:US
Practice Address - Phone:310-966-6610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT31641167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician