Provider Demographics
NPI:1619127446
Name:WOLOWITZ, LESLIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:
Last Name:WOLOWITZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W BELMONT AVE
Mailing Address - Street 2:206
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3200
Mailing Address - Country:US
Mailing Address - Phone:773-203-7464
Mailing Address - Fax:773-880-1323
Practice Address - Street 1:1300 W BELMONT AVE
Practice Address - Street 2:206
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3200
Practice Address - Country:US
Practice Address - Phone:773-203-7464
Practice Address - Fax:773-880-1323
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-29
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004789103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical