MEDICARE: LESLIE ELAINE LUTTRELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	89600	TX

General Provider Information

NPI Number	:	1144942681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE ELAINE LUTTRELL

Provider Business Mailing Address
First Line	:	503 ARBOR CREEK DR
Second Line	:
City	:	EULESS
State	:	TX
Zip	:	76039-3706
Country	:	US
Telephone Number	:	903-646-4957
Fax Number	:

Provider Business Practice Location Address
First Line	:	503 ARBOR CREEK DR
Second Line	:
City	:	EULESS
State	:	TX
Zip	:	76039-3706
Country	:	US
Telephone Number	:	903-646-4957
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2022
Last Update Date	:	09/12/2022

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