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General NPI Number Information
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NPI Number | 1568984664
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Entity Type | Individual
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Provider Name | ANDIE MAIKA LESLIE PH.D.
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Gender |
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Dates
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Enumeration Date | 07/10/2017
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Last Update Date | 07/16/2024
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Provider Practice Location Address
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Address Line | 516 CYPRESS ST
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City | FORT BRAGG
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State | CA
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Zip | 95437-5410
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Country | US
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Telephone | 707-961-0308
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2077
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City | UKIAH
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State | CA
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Zip | 95482-2077
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Country | US
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Telephone | 707-467-2010
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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 | PSB94027727
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License Number State | CA
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