Provider Demographics
NPI:1669839908
Name:LESLIE, MYKAL JOSIA (PC, CRC)
Entity Type:Individual
Prefix:MR
First Name:MYKAL
Middle Name:JOSIA
Last Name:LESLIE
Suffix:
Gender:M
Credentials:PC, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:447 NORTHEAST AVE
Mailing Address - Street 2:APT. A206
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278-1483
Mailing Address - Country:US
Mailing Address - Phone:740-336-2473
Mailing Address - Fax:
Practice Address - Street 1:87 N CANTON RD
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44305-3838
Practice Address - Country:US
Practice Address - Phone:330-794-4254
Practice Address - Fax:330-794-4262
Is Sole Proprietor?:No
Enumeration Date:2016-01-18
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC1200603101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor