Provider Demographics
NPI:1821758012
Name:DOMINICK, LESLIE HAALAND (MS, LCPC)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:HAALAND
Last Name:DOMINICK
Suffix:
Gender:F
Credentials:MS, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10619 KELLY CANYON RD
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-9688
Mailing Address - Country:US
Mailing Address - Phone:406-478-6611
Mailing Address - Fax:
Practice Address - Street 1:2050 FAIRWAY DR STE 203
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-5810
Practice Address - Country:US
Practice Address - Phone:406-478-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCPC-LIC-50557101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health