Provider Demographics
NPI:1164080719
Name:DEWBERRY, LESLIE FAY (LLPC)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:FAY
Last Name:DEWBERRY
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:FAY
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6271 ENOLA AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-8110
Mailing Address - Country:US
Mailing Address - Phone:269-806-0898
Mailing Address - Fax:
Practice Address - Street 1:1000 OAKLAND DR FL 3
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-1282
Practice Address - Country:US
Practice Address - Phone:269-387-8230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401009460101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional