Provider Demographics
NPI:1649769605
Name:LOOMIS, LESLIE JEAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:JEAN
Last Name:LOOMIS
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 1:23 CAMBRIDGE TER
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140-2620
Mailing Address - Country:US
Mailing Address - Phone:617-497-0097
Mailing Address - Fax:
Practice Address - Street 1:23 CAMBRIDGE TER
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02140-2620
Practice Address - Country:US
Practice Address - Phone:617-497-0097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-05
Last Update Date:2018-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4734103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool