Provider Demographics
NPI:1710197389
Name:GLENN, LESLIE K (LCMHC)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:K
Last Name:GLENN
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 461144
Mailing Address - Street 2:
Mailing Address - City:LEEDS
Mailing Address - State:UT
Mailing Address - Zip Code:84746-1144
Mailing Address - Country:US
Mailing Address - Phone:435-652-4596
Mailing Address - Fax:
Practice Address - Street 1:654 W CANYON CREEK DR
Practice Address - Street 2:
Practice Address - City:LEEDS
Practice Address - State:UT
Practice Address - Zip Code:84746
Practice Address - Country:US
Practice Address - Phone:435-652-4596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4540101YM0800X
UT47998256004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health