1245544204 NPI number — KRISTINA MARIE LESLIE LMFT-170

Table of content: KRISTINA MARIE LESLIE LMFT-170 (NPI 1245544204)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245544204 NPI number — KRISTINA MARIE LESLIE LMFT-170

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LESLIE
Provider First Name:
KRISTINA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMFT-170
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DORMAN
Provider Other First Name:
KRISTINA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1245544204
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3907 CHIPPEWA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GILLETTE
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82718-6674
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-682-3747
Provider Business Mailing Address Fax Number:
307-682-3748

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3907 CHIPPEWA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GILLETTE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82718-6674
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-922-3043
Provider Business Practice Location Address Fax Number:
307-363-4807
Provider Enumeration Date:
08/02/2010

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: 106H00000X , with the licence number:  LMFT-170 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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