Provider Demographics
NPI:1710375134
Name:FRASER, LESLIE (PHD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:FRASER
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 1:2900 W CYPRESS CREEK RD
Mailing Address - Street 2:#2
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-1715
Mailing Address - Country:US
Mailing Address - Phone:954-915-7444
Mailing Address - Fax:954-206-0372
Practice Address - Street 1:2900 W CYPRESS CREEK RD
Practice Address - Street 2:#2
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-1715
Practice Address - Country:US
Practice Address - Phone:954-915-7444
Practice Address - Fax:954-206-0372
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9222103TC0700X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling