Healthcare Provider Details

I. General information

NPI: 1952494593
Provider Name (Legal Business Name): LESLEY M MANSON PSY-D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LESLEY SHAW PSY.D.

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 06/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 N 3RD ST DBH PROGRAM
PHOENIX AZ
85004-2154
US

IV. Provider business mailing address

2468 S MARBLE ST
GILBERT AZ
85295-7134
US

V. Phone/Fax

Practice location:
  • Phone: 602-496-6790
  • Fax:
Mailing address:
  • Phone: 602-369-3343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4586
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY20454
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: