Healthcare Provider Details

I. General information

NPI: 1104295963
Provider Name (Legal Business Name): LESLIE GODWIN CGC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LESLIE HARLESS CGC

II. Dates (important events)

Enumeration Date: 09/22/2015
Last Update Date: 09/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3741 RUTLEDGE RD NE
ALBUQUERQUE NM
87109-5566
US

IV. Provider business mailing address

3741 RUTLEDGE RD NE
ALBUQUERQUE NM
87109-5566
US

V. Phone/Fax

Practice location:
  • Phone: 505-798-9300
  • Fax:
Mailing address:
  • Phone: 505-798-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License NumberGC2012-002
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: