Healthcare Provider Details

I. General information

NPI: 1124296280
Provider Name (Legal Business Name): LESLIE JANE GUINAUGH SUPKOFF MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LESLIE JANE GUINAUGH MFT

II. Dates (important events)

Enumeration Date: 02/12/2008
Last Update Date: 02/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

554 S SAN VICENTE BLVD STE 102
LOS ANGELES CA
90048-4652
US

IV. Provider business mailing address

251 N SWALL DR
BEVERLY HILLS CA
90211-1712
US

V. Phone/Fax

Practice location:
  • Phone: 310-663-4244
  • Fax:
Mailing address:
  • Phone: 310-271-7764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberMFC 30843
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMFC 30843
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: