Provider Demographics
NPI:1659819118
Name:PENFOLD, LESLIE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:PENFOLD
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 1:23427 SE 243RD PL
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-5268
Mailing Address - Country:US
Mailing Address - Phone:206-910-3410
Mailing Address - Fax:
Practice Address - Street 1:3214 W MCGRAW ST
Practice Address - Street 2:STE 212
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98199-3239
Practice Address - Country:US
Practice Address - Phone:206-453-4882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-05
Last Update Date:2017-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60732858106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst