Provider Demographics
NPI:1093489692
Name:GUSTAFSON, LESLEY WEBER (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:LESLEY
Middle Name:WEBER
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 MAPLE LANE
Mailing Address - Street 2:
Mailing Address - City:NORTHBORO
Mailing Address - State:MA
Mailing Address - Zip Code:01532
Mailing Address - Country:US
Mailing Address - Phone:508-561-4531
Mailing Address - Fax:508-393-8782
Practice Address - Street 1:73 MAPLE LANE
Practice Address - Street 2:
Practice Address - City:NORTHBORO
Practice Address - State:MA
Practice Address - Zip Code:01532
Practice Address - Country:US
Practice Address - Phone:508-561-4531
Practice Address - Fax:508-393-8782
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALMHC876101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health