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General NPI Number Information
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NPI Number | 1063398238
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Entity Type | Individual
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Provider Name | LESLIE K POULOS PSYD, HSPP
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Gender |
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Dates
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Enumeration Date | 08/13/2025
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Last Update Date | 08/13/2025
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Provider Practice Location Address
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Address Line | 2010 N DAMEN AVE UNIT F
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City | CHICAGO
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State | IL
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Zip | 60647-3286
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Country | US
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Telephone | 773-887-6447
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Fax |
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Provider Business Mailing Address
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Address Line | 7230 OLCOTT AVE
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City | HAMMOND
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State | IN
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Zip | 46323-2044
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Country | US
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Telephone | 219-616-3646
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 20043979B
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071.022302
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License Number State | IL
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