Provider Demographics
NPI:1689766750
Name:MACK, LESLIE RAE (LPC MS NCC)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:RAE
Last Name:MACK
Suffix:
Gender:F
Credentials:LPC MS NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 MAIN AVE
Mailing Address - Street 2:310
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103
Mailing Address - Country:US
Mailing Address - Phone:701-371-8411
Mailing Address - Fax:
Practice Address - Street 1:510 4TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103
Practice Address - Country:US
Practice Address - Phone:701-476-7200
Practice Address - Fax:701-476-7273
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5085104101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional