Provider Demographics
NPI:1184880007
Name:DAVIS, LESLEY R (MFC)
Entity type:Individual
Prefix:
First Name:LESLEY
Middle Name:R
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MFC
Other - Prefix:
Other - First Name:LESLEY
Other - Middle Name:R
Other - Last Name:DAVIS-QUIRARTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MFC
Mailing Address - Street 1:112 CALLE REDONDEL
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-3872
Mailing Address - Country:US
Mailing Address - Phone:949-468-9121
Mailing Address - Fax:
Practice Address - Street 1:55 FAIR DR
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-6520
Practice Address - Country:US
Practice Address - Phone:949-468-9121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-30
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42888106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist