Provider Demographics
NPI:1447301866
Name:LESLIE, CONSTANCE FORTIN
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:FORTIN
Last Name:LESLIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CONSTANCE
Other - Middle Name:RHEA
Other - Last Name:FORTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW LCSW
Mailing Address - Street 1:3241 CIRCA DE TIERRA
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-6908
Mailing Address - Country:US
Mailing Address - Phone:858-759-7048
Mailing Address - Fax:
Practice Address - Street 1:4311 3RD AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-1407
Practice Address - Country:US
Practice Address - Phone:619-688-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA192061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical