Provider Demographics
NPI:1033274402
Name:BURGESS, LESLIE (LCPC)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 S ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-3833
Mailing Address - Country:US
Mailing Address - Phone:406-542-5655
Mailing Address - Fax:406-542-7005
Practice Address - Street 1:821 S ORANGE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-3833
Practice Address - Country:US
Practice Address - Phone:406-542-5655
Practice Address - Fax:406-542-7005
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT289101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0250003Medicaid
MT74681OtherBCBS