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General NPI Number Information
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NPI Number | 1497803084
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Entity Type | Organization
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Legal Business Name | LIGHTSPACE, INC.
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Dates
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Enumeration Date | 01/08/2007
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 1275 BIG FLAT RD
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City | MISSOULA
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State | MT
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Zip | 59804-9217
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Country | US
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Telephone | 406-728-1413
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Fax |
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Provider Business Mailing Address
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Address Line | 1275 BIG FLAT RD
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City | MISSOULA
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State | MT
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Zip | 59804-9217
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Country | US
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Telephone | 406-728-1413
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JODI LESLIE
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Credential | PH.D, LCPC
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Telephone | 406-728-1413
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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 | 960
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License Number State | MT
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 115184-2501
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License Number State | UT
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