Provider Demographics
NPI:1952078750
Name:DAVIDSON, LESLIE MARIE (MC, LAC)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:MARIE
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:MC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5007 S TERRACE RD
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7273
Mailing Address - Country:US
Mailing Address - Phone:480-776-4712
Mailing Address - Fax:
Practice Address - Street 1:4801 S LAKESHORE DR STE 204
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7157
Practice Address - Country:US
Practice Address - Phone:480-256-9299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-27
Last Update Date:2022-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20203101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health