Provider Demographics
NPI:1972595684
Name:SUGA, LESLIE JAY (PHD HSPP)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:JAY
Last Name:SUGA
Suffix:
Gender:M
Credentials:PHD HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8539 TIDEWATER DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-8917
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6515 E 82ND ST
Practice Address - Street 2:SUITE 210
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-1576
Practice Address - Country:US
Practice Address - Phone:317-559-0990
Practice Address - Fax:317-653-6405
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2014-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040349A103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100376990AMedicaid
IN680013641OtherMEDICARE RAILROAD
INR34163Medicare UPIN
IN100376990AMedicaid
246350GMedicare PIN
IN680013641OtherMEDICARE RAILROAD