Provider Demographics
NPI:1114383395
Name:FAZELI, LEILA
Entity Type:Individual
Prefix:
First Name:LEILA
Middle Name:
Last Name:FAZELI
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 1:76 CRANBROOK RD UNIT 291
Mailing Address - Street 2:
Mailing Address - City:COCKEYSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21030-3404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9475 DEERECO RD
Practice Address - Street 2:SUITE 410 CORE COUNSELING
Practice Address - City:LUTHERVILLE TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-2118
Practice Address - Country:US
Practice Address - Phone:301-305-9174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP6760101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health