=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457507121
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LESLIE PAM PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2008
-----------------------------------------------------
Last Update Date | 08/13/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10379 W PICO BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90064-2608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-275-3836
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9185 THRASHER AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90069-1144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFT 04523
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------