Provider Demographics
NPI:1043372634
Name:JOHNSEN, LESLIE (MA, LLP)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:JOHNSEN
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:AYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LLP
Mailing Address - Street 1:888 W BIG BEAVER RD STE 1450
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4762
Mailing Address - Country:US
Mailing Address - Phone:248-244-8644
Mailing Address - Fax:248-244-1330
Practice Address - Street 1:888 W BIG BEAVER RD STE 1450
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4762
Practice Address - Country:US
Practice Address - Phone:248-244-8644
Practice Address - Fax:248-244-1330
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009715103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling