Provider Demographics
NPI:1245544204
Name:LESLIE, KRISTINA MARIE (LMFT-170)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MARIE
Last Name:LESLIE
Suffix:
Gender:F
Credentials:LMFT-170
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:MARIE
Other - Last Name:DORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3907 CHIPPEWA AVE
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-6674
Mailing Address - Country:US
Mailing Address - Phone:307-682-3747
Mailing Address - Fax:307-682-3748
Practice Address - Street 1:3907 CHIPPEWA AVE
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-6674
Practice Address - Country:US
Practice Address - Phone:949-922-3043
Practice Address - Fax:307-363-4807
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLMFT-170106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist