Provider Demographics
NPI:1821086372
Name:PRUYN, LESLIE K (MA)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:K
Last Name:PRUYN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:PRUYN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:1444 N FARNSWORTH AVE
Mailing Address - Street 2:#109
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60505-1640
Mailing Address - Country:US
Mailing Address - Phone:630-202-3062
Mailing Address - Fax:
Practice Address - Street 1:1444 N FARNSWORTH AVE
Practice Address - Street 2:#109
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60505-1640
Practice Address - Country:US
Practice Address - Phone:630-202-3062
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional