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General NPI Number Information
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NPI Number | 1417061466
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Entity Type | Organization
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Legal Business Name | LESLIE H PETRUK MA LPC NCC
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Dates
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Enumeration Date | 08/18/2006
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Last Update Date | 03/13/2013
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Provider Practice Location Address
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Address Line | 1106 HARDING PL
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City | CHARLOTTE
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State | NC
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Zip | 28204-2825
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Country | US
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Telephone | 704-665-0065
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Fax | 704-335-4001
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Provider Business Mailing Address
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Address Line | 1106 HARDING PL
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City | CHARLOTTE
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State | NC
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Zip | 28204-2825
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Country | US
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Telephone | 704-604-8023
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Fax | 704-335-4001
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Authorized Official
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Title or Position | DIRECTOR
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Name | LESLIE H PETRUK
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Credential | LPC, BCC
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Telephone | 704-604-8023
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 4290
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License Number State | NC
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