Healthcare Provider Details

I. General information

NPI: 1245544204
Provider Name (Legal Business Name): KRISTINA MARIE LESLIE LMFT-170
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KRISTINA MARIE DORMAN

II. Dates (important events)

Enumeration Date: 08/02/2010
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3907 CHIPPEWA AVE
GILLETTE WY
82718-6674
US

IV. Provider business mailing address

3907 CHIPPEWA AVE
GILLETTE WY
82718-6674
US

V. Phone/Fax

Practice location:
  • Phone: 949-922-3043
  • Fax: 307-363-4807
Mailing address:
  • Phone: 307-682-3747
  • Fax: 307-682-3748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT-170
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: