Basic Information
| Provider Information | |||||||||
| NPI: | 1407282221 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IRAZOQUE-GOMEZ | ||||||||
| FirstName: | LESLIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1963 N E ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924053919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098816146 | ||||||||
| FaxNumber: | 9098810111 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 E GILBERT ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924153919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093877200 | ||||||||
| FaxNumber: | 9093877717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2013 | ||||||||
| LastUpdateDate: | 12/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.