Provider Demographics
NPI:1063398238
Name:POULOS, LESLIE K (PSYD, HSPP)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:K
Last Name:POULOS
Suffix:
Gender:X
Credentials:PSYD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7230 OLCOTT AVE
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:IN
Mailing Address - Zip Code:46323-2044
Mailing Address - Country:US
Mailing Address - Phone:219-616-3646
Mailing Address - Fax:
Practice Address - Street 1:2010 N DAMEN AVE UNIT F
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-3286
Practice Address - Country:US
Practice Address - Phone:773-887-6447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-13
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20043979B103TC0700X
IL071.022302103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical