Healthcare Provider Details

I. General information

NPI: 1922374446
Provider Name (Legal Business Name): LESLIE ANDERSON JAY LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2012
Last Update Date: 03/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3116 30TH AVE SUITE 203
ASTORIA NY
11102-1571
US

IV. Provider business mailing address

3116 30TH AVE SUITE 203
ASTORIA NY
11102-1571
US

V. Phone/Fax

Practice location:
  • Phone: 800-403-4360
  • Fax:
Mailing address:
  • Phone: 800-403-4360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number005755
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: