Healthcare Provider Details

I. General information

NPI: 1710197389
Provider Name (Legal Business Name): LESLIE K GLENN LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 02/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

654 W CANYON CREEK DR
LEEDS UT
84746
US

IV. Provider business mailing address

PO BOX 461144
LEEDS UT
84746-1144
US

V. Phone/Fax

Practice location:
  • Phone: 435-652-4596
  • Fax:
Mailing address:
  • Phone: 435-652-4596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4540
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number47998256004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: