Provider Demographics
NPI:1548838568
Name:CARRASCO, LEONIDAS EDMUNDO
Entity type:Individual
Prefix:
First Name:LEONIDAS
Middle Name:EDMUNDO
Last Name:CARRASCO
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 1:3979 ALHAMBRA AVE APT 211
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-3836
Mailing Address - Country:US
Mailing Address - Phone:510-621-4566
Mailing Address - Fax:
Practice Address - Street 1:1625 FILBERT ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-2890
Practice Address - Country:US
Practice Address - Phone:510-663-9092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-15
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner