Provider Demographics
NPI:1083231435
Name:GLUCK, LESLIE (MA, AMFT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:GLUCK
Suffix:
Gender:F
Credentials:MA, AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 S ELM DR APT 301
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-3321
Mailing Address - Country:US
Mailing Address - Phone:310-486-5881
Mailing Address - Fax:
Practice Address - Street 1:11835 W OLYMPIC BLVD STE 815
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-5056
Practice Address - Country:US
Practice Address - Phone:310-428-7240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA112715101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health