Provider Demographics
NPI:1306960562
Name:HERMOSILLO, LESLIE GRANDE
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:GRANDE
Last Name:HERMOSILLO
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 1:333 S BEAUDRY AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-1466
Mailing Address - Country:US
Mailing Address - Phone:213-241-3814
Mailing Address - Fax:213-241-3305
Practice Address - Street 1:333 S BEAUDRY AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017
Practice Address - Country:US
Practice Address - Phone:213-241-3814
Practice Address - Fax:213-241-3305
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical