Provider Demographics
NPI:1962212167
Name:ROYBAL, LESLIE KRISTINE (RADT)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:KRISTINE
Last Name:ROYBAL
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2403 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3007
Mailing Address - Country:US
Mailing Address - Phone:707-360-4387
Mailing Address - Fax:
Practice Address - Street 1:790 SONOMA AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4713
Practice Address - Country:US
Practice Address - Phone:707-360-4368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1520300823101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)