Provider Demographics
NPI:1417061466
Name:LESLIE H PETRUK MA LPC NCC
Entity Type:Organization
Organization Name:LESLIE H PETRUK MA LPC NCC
Other - Org Name:THE STONE CENTER FOR COUNSELING & LEADERSHIP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:H
Authorized Official - Last Name:PETRUK
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, BCC
Authorized Official - Phone:704-604-8023
Mailing Address - Street 1:1106 HARDING PL
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2825
Mailing Address - Country:US
Mailing Address - Phone:704-604-8023
Mailing Address - Fax:704-335-4001
Practice Address - Street 1:1106 HARDING PL
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2825
Practice Address - Country:US
Practice Address - Phone:704-665-0065
Practice Address - Fax:704-335-4001
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE STONE CENTER FOR COUNSELING & LEADERSHIP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-18
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4290101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1386GOtherBC/BS PROVIDER NUMBER
NC6102653Medicaid