Provider Demographics
NPI:1982042040
Name:FILLAK, LESLI (LMFT)
Entity Type:Individual
Prefix:
First Name:LESLI
Middle Name:
Last Name:FILLAK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:LESLI
Other - Middle Name:
Other - Last Name:HARAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:100 EXECUTIVE PARK DR. STE 100
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4210
Mailing Address - Country:US
Mailing Address - Phone:844-468-5050
Mailing Address - Fax:216-456-8128
Practice Address - Street 1:100 EXECUTIVE PARK DR. STE 100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4210
Practice Address - Country:US
Practice Address - Phone:844-468-5050
Practice Address - Fax:216-456-8128
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY168890106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100419140Medicaid