Provider Demographics
NPI:1255461372
Name:KOOYMAN, LESLIE E (PHD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:E
Last Name:KOOYMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 STONEBRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1716
Mailing Address - Country:US
Mailing Address - Phone:704-806-0490
Mailing Address - Fax:
Practice Address - Street 1:2010 STONEBRIDGE LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1716
Practice Address - Country:US
Practice Address - Phone:704-806-0490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YP2500X101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional