Healthcare Provider Details

I. General information

NPI: 1205178050
Provider Name (Legal Business Name): LESLIE DALENCOUR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2013
Last Update Date: 09/22/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3739 WILKENS AVE
BALTIMORE MD
21229-5035
US

IV. Provider business mailing address

5622 OAKLAND MILLS RD
COLUMBIA MD
21045-3218
US

V. Phone/Fax

Practice location:
  • Phone: 410-621-9261
  • Fax: 410-514-3596
Mailing address:
  • Phone: 718-496-4223
  • Fax: 410-514-3596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC6559
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: