Provider Demographics
NPI:1144048406
Name:HULLON, LEEANTHONY (PEER SUPPORT)
Entity type:Individual
Prefix:
First Name:LEEANTHONY
Middle Name:
Last Name:HULLON
Suffix:
Gender:M
Credentials:PEER SUPPORT
Other - Prefix:
Other - First Name:LEEANTHONY
Other - Middle Name:
Other - Last Name:HULLON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PEER SUPPORT
Mailing Address - Street 1:2340 S CLARA AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93706-4308
Mailing Address - Country:US
Mailing Address - Phone:415-269-1593
Mailing Address - Fax:
Practice Address - Street 1:2340 S CLARA AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706-4308
Practice Address - Country:US
Practice Address - Phone:415-269-1593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty