Basic Information
Provider Information | |||||||||
NPI: | 1295039485 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BEKKE | ||||||||
FirstName: | LEONARD | ||||||||
MiddleName: | UKOETTE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | IBEKWE | ||||||||
OtherFirstName: | UKOETTE | ||||||||
OtherMiddleName: | SANDY | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 13724 CHADRON AVE APT 26 | ||||||||
Address2: |   | ||||||||
City: | HAWTHORNE | ||||||||
State: | CA | ||||||||
PostalCode: | 902507835 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3107068537 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 901 N PACIFIC COAST HWY | ||||||||
Address2: | SUITE 200A | ||||||||
City: | REDONDO BEACH | ||||||||
State: | CA | ||||||||
PostalCode: | 902772162 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3103161610 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/01/2011 | ||||||||
LastUpdateDate: | 03/22/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF 69420 | CA | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
No ID Information.