Provider Demographics
NPI:1629441191
Name:MCELLISTREM, LEAH MARJORIE (LMFT)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:MARJORIE
Last Name:MCELLISTREM
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 1:1123 GRAND AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-2744
Mailing Address - Country:US
Mailing Address - Phone:651-352-7105
Mailing Address - Fax:
Practice Address - Street 1:1123 GRAND AVE APT 203
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-2744
Practice Address - Country:US
Practice Address - Phone:651-352-7105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3289106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist