Provider Demographics
NPI:1447461363
Name:LEEDOM, COURTNEY JEAN
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:JEAN
Last Name:LEEDOM
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:P.O. BOX 1533
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92856-1533
Mailing Address - Country:US
Mailing Address - Phone:714-532-6713
Mailing Address - Fax:714-223-0663
Practice Address - Street 1:1234 W CHAPMAN AVE STE 101
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-2862
Practice Address - Country:US
Practice Address - Phone:714-532-6713
Practice Address - Fax:714-223-0663
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC41709106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist