Provider Demographics
NPI:1710464003
Name:LESLIE J WONDRA LLC
Entity Type:Organization
Organization Name:LESLIE J WONDRA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:WONDRA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:954-787-9869
Mailing Address - Street 1:8958 W STATE ROAD 84 STE 191
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33324-4457
Mailing Address - Country:US
Mailing Address - Phone:954-787-9869
Mailing Address - Fax:
Practice Address - Street 1:8958 W STATE ROAD 84 STE 191
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33324-4457
Practice Address - Country:US
Practice Address - Phone:954-787-9869
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-19
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW-10031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty