Provider Demographics
NPI:1326627266
Name:WILBORNE, LESLIE E (NCC)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:E
Last Name:WILBORNE
Suffix:
Gender:F
Credentials:NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 FISCO DR
Mailing Address - Street 2:
Mailing Address - City:EAST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06513-1202
Mailing Address - Country:US
Mailing Address - Phone:917-557-6071
Mailing Address - Fax:
Practice Address - Street 1:446 BLAKE ST # 200
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06515-4407
Practice Address - Country:US
Practice Address - Phone:203-387-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT46.004839101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health