Basic Information
| Provider Information | |||||||||
| NPI: | 1740452648 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LELAND | ||||||||
| FirstName: | GAYLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2533 W MCKINLEY AVE | ||||||||
| Address2: | #169 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937281035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594431499 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3467 W SHAW AVE | ||||||||
| Address2: | SUITE #102 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937113223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592740299 | ||||||||
| FaxNumber: | 5592740292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2008 | ||||||||
| LastUpdateDate: | 03/31/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | CA | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 07416 | 01 | CA | CAADE DRUG AND ALCOHOL | OTHER |