Basic Information
| Provider Information | |||||||||
| NPI: | 1407989916 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUNOZ | ||||||||
| FirstName: | LEO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35578 N GOLDRUSH LN | ||||||||
| Address2: | |||||||||
| City: | QUEEN CREEK | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852427805 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 14780 W MOUNTAIN VIEW BLVD STE 110 | ||||||||
| Address2: | |||||||||
| City: | SURPRISE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853747280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233747774 | ||||||||
| FaxNumber: | 8554206361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 08/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PSY-000300 | AZ | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 118168 | 05 | AZ | MEDICAID |