Provider Demographics
NPI:1174031561
Name:ROBERTSON, LESLIE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:ROBERTSON
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 1:4020 FOLKER ST
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5321
Mailing Address - Country:US
Mailing Address - Phone:907-563-1000
Mailing Address - Fax:
Practice Address - Street 1:926 ASPEN ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-5501
Practice Address - Country:US
Practice Address - Phone:907-563-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-19
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.004356101YP2500X
221700000X
AK129763101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist