Provider Demographics
NPI:1558952119
Name:GILLIAM, LESLIE (LMFT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3475 BARRY AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-2001
Mailing Address - Country:US
Mailing Address - Phone:310-701-0997
Mailing Address - Fax:
Practice Address - Street 1:12316 VENICE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-3802
Practice Address - Country:US
Practice Address - Phone:310-402-2229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA123321106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist