Healthcare Provider Details

I. General information

NPI: 1578855672
Provider Name (Legal Business Name): MS. LESLIE MARIE BERUMEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LESLIE SWANSTROM

II. Dates (important events)

Enumeration Date: 05/06/2011
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 W BROWN DEER RD STE 200
BROWN DEER WI
53209-1220
US

IV. Provider business mailing address

3090 N 53RD ST
MILWAUKEE WI
53210-1617
US

V. Phone/Fax

Practice location:
  • Phone: 414-540-2170
  • Fax:
Mailing address:
  • Phone: 414-449-4444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7585-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: