Provider Demographics
NPI:1245462811
Name:JOHNSEN, LESLEY (DAC, LAC, MA)
Entity type:Individual
Prefix:
First Name:LESLEY
Middle Name:
Last Name:JOHNSEN
Suffix:
Gender:F
Credentials:DAC, LAC, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 E VIRGINIA AVE STE 170
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1124
Mailing Address - Country:US
Mailing Address - Phone:480-717-7838
Mailing Address - Fax:
Practice Address - Street 1:99 E VIRGINIA AVE STE 170
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1124
Practice Address - Country:US
Practice Address - Phone:480-717-7838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0977171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty