Provider Demographics
NPI:1609555812
Name:MCDONALD, LESLIE JEAN
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:JEAN
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-0520
Mailing Address - Country:US
Mailing Address - Phone:505-852-6710
Mailing Address - Fax:505-852-1827
Practice Address - Street 1:HIGHWAY 68 CR 49 PRIVATE DR. 1098
Practice Address - Street 2:
Practice Address - City:VELARDE
Practice Address - State:NM
Practice Address - Zip Code:87582
Practice Address - Country:US
Practice Address - Phone:505-852-6170
Practice Address - Fax:505-852-1827
Is Sole Proprietor?:No
Enumeration Date:2023-07-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2023-0169101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health