Provider Demographics
NPI:1356567846
Name:OLECK, LESLIE G (CNS, LMFT)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:G
Last Name:OLECK
Suffix:
Gender:F
Credentials:CNS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9670 E WASHINGTON ST
Practice Address - Street 2:STE120
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-3032
Practice Address - Country:US
Practice Address - Phone:317-890-5700
Practice Address - Fax:317-890-5717
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001274A106H00000X
IN35001274364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200976370Medicaid
IN676290RMedicare PIN
IN200976370Medicaid