Provider Demographics
NPI:1366439887
Name:GRAHAM, LESLIE J (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:J
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:LESLIE
Other - Middle Name:GRAHAM
Other - Last Name:FORLANO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:18609 W CAPISTRANO AVE
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-4900
Mailing Address - Country:US
Mailing Address - Phone:480-244-6761
Mailing Address - Fax:623-776-9921
Practice Address - Street 1:8253 W THUNDERBIRD RD
Practice Address - Street 2:SUITE 103
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4616
Practice Address - Country:US
Practice Address - Phone:480-244-6761
Practice Address - Fax:623-776-9921
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12303101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health