Provider Demographics
NPI:1629689583
Name:MONTIJO-TAI, LESLIE (PSY-D)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:MONTIJO-TAI
Suffix:
Gender:F
Credentials:PSY-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 N 16TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-1823
Mailing Address - Country:US
Mailing Address - Phone:602-218-8194
Mailing Address - Fax:
Practice Address - Street 1:2225 N 16TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-1823
Practice Address - Country:US
Practice Address - Phone:602-218-8194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPSY-004905103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical