Provider Demographics
NPI:1417053703
Name:KLOCKOW, LESLIE BARTLETT (LCPC)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:BARTLETT
Last Name:KLOCKOW
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 EVERETT ST
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2403
Mailing Address - Country:US
Mailing Address - Phone:207-729-7710
Mailing Address - Fax:207-729-7801
Practice Address - Street 1:9 EVERETT ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2403
Practice Address - Country:US
Practice Address - Phone:207-729-7710
Practice Address - Fax:207-729-7801
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC 766101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional