Provider Demographics
NPI:1457798225
Name:KOMATSU, LESLIE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:
Last Name:KOMATSU
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 E 1300 S
Mailing Address - Street 2:SUITE 501
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-5482
Mailing Address - Country:US
Mailing Address - Phone:385-468-3495
Mailing Address - Fax:385-468-3560
Practice Address - Street 1:145 E 1300 S
Practice Address - Street 2:SUITE 501
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-5482
Practice Address - Country:US
Practice Address - Phone:385-468-3495
Practice Address - Fax:385-468-3560
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT110021-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical