Provider Demographics
NPI:1699277251
Name:WILSON, LESLIE MARGARITA
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:MARGARITA
Last Name:WILSON
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 1:615 N BUSH ST UNIT 1003
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92702-2248
Mailing Address - Country:US
Mailing Address - Phone:310-390-6612
Mailing Address - Fax:
Practice Address - Street 1:2900 BRISTOL ST STE 103
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5981
Practice Address - Country:US
Practice Address - Phone:714-540-9070
Practice Address - Fax:714-884-4347
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-28
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1315890718101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)