1104077007 NPI number — LESLIE M STAFF LCPC, LMHC

Table of content: LESLIE M STAFF LCPC, LMHC (NPI 1104077007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104077007 NPI number — LESLIE M STAFF LCPC, LMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STAFF
Provider First Name:
LESLIE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCPC, LMHC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104077007
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3368 WASHINGTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02130-2612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-892-7827
Provider Business Mailing Address Fax Number:
617-522-0348

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3368 WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02130-2612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-892-7827
Provider Business Practice Location Address Fax Number:
617-522-0348
Provider Enumeration Date:
10/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  XL3442 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 433129599 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9066 . This is a "LICENSED MENTAL HEALTH COUNSELOR LICENSE NUMBER" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: CC3690 . This is a "LICENSED CLINICAL PROFESSIONAL COUNSELOR LICENSE NUMBER" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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