Provider Demographics
NPI:1205178050
Name:DALENCOUR, LESLIE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:DALENCOUR
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 1:5622 OAKLAND MILLS RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-3218
Mailing Address - Country:US
Mailing Address - Phone:718-496-4223
Mailing Address - Fax:410-514-3596
Practice Address - Street 1:3739 WILKENS AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-5035
Practice Address - Country:US
Practice Address - Phone:410-621-9261
Practice Address - Fax:410-514-3596
Is Sole Proprietor?:No
Enumeration Date:2013-03-20
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDLC6559101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD589561800Medicaid