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General NPI Number Information
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NPI Number | 1609555812
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Entity Type | Individual
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Provider Name | LESLIE JEAN MCDONALD
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Gender | Female
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Dates
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Enumeration Date | 07/14/2023
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Last Update Date | 07/14/2023
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Provider Practice Location Address
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Address Line | HIGHWAY 68 CR 49 PRIVATE DR. 1098
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City | VELARDE
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State | NM
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Zip | 87582
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Country | US
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Telephone | 505-852-6170
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Fax | 505-852-1827
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Provider Business Mailing Address
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Address Line | PO BOX 520
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City | ESPANOLA
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State | NM
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Zip | 87532-0520
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Country | US
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Telephone | 505-852-6710
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Fax | 505-852-1827
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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 | CTB-2023-0169
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License Number State | NM
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