Provider Demographics
NPI:1184779993
Name:MULLIGAN, LESLIE (LPC, LCPC)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:MULLIGAN
Suffix:
Gender:F
Credentials:LPC, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3515 W MARKET ST STE 120
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27403-4441
Mailing Address - Country:US
Mailing Address - Phone:336-323-2660
Mailing Address - Fax:
Practice Address - Street 1:3515 W MARKET ST STE 120
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-4441
Practice Address - Country:US
Practice Address - Phone:336-323-2660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC3059101YM0800X, 101YP2500X
NC13266101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME26-2062123OtherFEIN