Provider Demographics
NPI:1053141432
Name:LE, NATHAN
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:LE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16414 SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-2042
Mailing Address - Country:US
Mailing Address - Phone:714-928-0270
Mailing Address - Fax:
Practice Address - Street 1:1901 CARNEGIE AVE STE 1C
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-5504
Practice Address - Country:US
Practice Address - Phone:714-848-8319
Practice Address - Fax:714-596-6274
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-15-21037106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician