Healthcare Provider Details

I. General information

NPI: 1700384054
Provider Name (Legal Business Name): LESLIE BROOKE DELONG PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2018
Last Update Date: 03/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 J ST STE 201
LINCOLN NE
68508-2900
US

IV. Provider business mailing address

650 J ST STE 201
LINCOLN NE
68508-2900
US

V. Phone/Fax

Practice location:
  • Phone: 402-413-6430
  • Fax:
Mailing address:
  • Phone: 402-413-6430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number576
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number576
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number576
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: