Provider Demographics
NPI:1750690251
Name:HANWAY, LESLIE ANN
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANN
Last Name:HANWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 S ATLANTIC BLVD
Mailing Address - Street 2:STE. #101
Mailing Address - City:COMMERCE
Mailing Address - State:CA
Mailing Address - Zip Code:90040-1200
Mailing Address - Country:US
Mailing Address - Phone:323-318-9960
Mailing Address - Fax:
Practice Address - Street 1:2450 S ATLANTIC BLVD
Practice Address - Street 2:STE. #101
Practice Address - City:COMMERCE
Practice Address - State:CA
Practice Address - Zip Code:90040-1200
Practice Address - Country:US
Practice Address - Phone:323-318-9960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-30
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 64923106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATYPE #95-2633765OtherMEDI-CAL