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General NPI Number Information
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NPI Number | 1124296280
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Entity Type | Individual
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Provider Name | LESLIE JANE GUINAUGH SUPKOFF MFT
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Gender | Female
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Dates
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Enumeration Date | 02/12/2008
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Last Update Date | 02/12/2008
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Provider Practice Location Address
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Address Line | 554 S SAN VICENTE BLVD STE 102
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City | LOS ANGELES
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State | CA
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Zip | 90048-4652
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Country | US
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Telephone | 310-663-4244
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Fax |
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Provider Business Mailing Address
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Address Line | 251 N SWALL DR
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City | BEVERLY HILLS
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State | CA
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Zip | 90211-1712
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Country | US
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Telephone | 310-271-7764
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MFC 30843
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | MFC 30843
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License Number State | CA
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