Provider Demographics
NPI:1518492586
Name:KIRKENDOLL, LESLIE (LESLIE KIRKENDOLL)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:KIRKENDOLL
Suffix:
Gender:F
Credentials:LESLIE KIRKENDOLL
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:KIRKENDOLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MEDU
Mailing Address - Street 1:359 HIGHLAND VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-2481
Mailing Address - Country:US
Mailing Address - Phone:318-820-0862
Mailing Address - Fax:
Practice Address - Street 1:2715 MACKEY PL
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-2544
Practice Address - Country:US
Practice Address - Phone:318-220-8423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA008533661101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health