Provider Demographics
NPI:1346301181
Name:CONNELL, LESLIE REBECCA (LCSW)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:REBECCA
Last Name:CONNELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:REBA
Other - Middle Name:
Other - Last Name:CONNELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5845 COLLEGE AVE
Mailing Address - Street 2:#2
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618
Mailing Address - Country:US
Mailing Address - Phone:510-594-8224
Mailing Address - Fax:
Practice Address - Street 1:5845 COLLEGE AVE
Practice Address - Street 2:#2
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618
Practice Address - Country:US
Practice Address - Phone:510-594-8224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS19814103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ26657ZMedicare ID - Type Unspecified