Provider Demographics
NPI:1356153340
Name:FONTENOT CORMACK, LESLIE JOANN (MS, LPC-ASSOCIATE)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:JOANN
Last Name:FONTENOT CORMACK
Suffix:
Gender:F
Credentials:MS, LPC-ASSOCIATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 CARNABY DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-6382
Mailing Address - Country:US
Mailing Address - Phone:337-496-7657
Mailing Address - Fax:
Practice Address - Street 1:2118 BIRDCREEK DR STE 100
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-1020
Practice Address - Country:US
Practice Address - Phone:254-598-2266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-25
Last Update Date:2025-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX96776101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health