Provider Demographics
NPI:1952447369
Name:NATHANSON, LESLIE ELLEN (MA)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:ELLEN
Last Name:NATHANSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 LUANA ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3238
Mailing Address - Country:US
Mailing Address - Phone:505-438-3455
Mailing Address - Fax:505-438-0227
Practice Address - Street 1:1313 LUANA ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3238
Practice Address - Country:US
Practice Address - Phone:505-438-3455
Practice Address - Fax:505-438-0227
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLPCC0065182101Y00000X
NMLMT0442225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist