Provider Demographics
NPI:1871374413
Name:COGORNO, LESLIE KHEILA
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:KHEILA
Last Name:COGORNO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 E BROAD ST STE 15
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18018-5920
Mailing Address - Country:US
Mailing Address - Phone:484-347-2325
Mailing Address - Fax:
Practice Address - Street 1:443 LARCH LN
Practice Address - Street 2:
Practice Address - City:NAZARETH
Practice Address - State:PA
Practice Address - Zip Code:18064-9608
Practice Address - Country:US
Practice Address - Phone:484-347-2325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC014904101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty