Provider Demographics
NPI:1669430237
Name:MEYER, LESLIE JOHNSON (MA LP)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:JOHNSON
Last Name:MEYER
Suffix:
Gender:F
Credentials:MA LP
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:A
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3915 GOLDEN VALLEY ROAD
Mailing Address - Street 2:COURAGE CENTER
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4298
Mailing Address - Country:US
Mailing Address - Phone:763-520-0493
Mailing Address - Fax:763-520-0355
Practice Address - Street 1:3915 GOLDEN VALLEY ROAD
Practice Address - Street 2:COURAGE CENTER
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4298
Practice Address - Country:US
Practice Address - Phone:763-520-0493
Practice Address - Fax:763-520-0355
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3588103T00000X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
151758OtherU CARE
6267174OtherUBH
6552200OtherSOUTH DAKOTA MA
6269174OtherMEDICA
63D67MEOtherBCBS MINNESOTA
963371019242OtherPREFERRED ONE
HP27751OtherHEALTH PARTNERS