Healthcare Provider Details

I. General information

NPI: 1669605010
Provider Name (Legal Business Name): LESLY JANE HENDERSHOT PSY.D., BCBA-D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2009
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30503 GREENFIELD RD
SOUTHFIELD MI
48076-1594
US

IV. Provider business mailing address

26901 BEAUMONT BLVD
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 248-691-4744
  • Fax:
Mailing address:
  • Phone: 947-522-1867
  • Fax: 947-522-0307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number6301014875
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number6301014875
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: