Provider Demographics
NPI:1689286064
Name:ROSE, LESLIE
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5006 S CHARITON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90056-1359
Mailing Address - Country:US
Mailing Address - Phone:661-317-0811
Mailing Address - Fax:
Practice Address - Street 1:5739 CHESLEY AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-2423
Practice Address - Country:US
Practice Address - Phone:661-317-0811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 390200000X
CAACSW125403104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program