Provider Demographics
NPI:1699455568
Name:LEON, SELENA DENISE
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:DENISE
Last Name:LEON
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 1:608 TAMARACK DR
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-6020
Mailing Address - Country:US
Mailing Address - Phone:702-470-5226
Mailing Address - Fax:
Practice Address - Street 1:608 TAMARACK DR
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-6020
Practice Address - Country:US
Practice Address - Phone:702-470-5226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst