Provider Demographics
NPI:1750979498
Name:LESLIE-UNDERWOOD, KIM (MHC-LP, CASAC-2)
Entity type:Individual
Prefix:MS
First Name:KIM
Middle Name:
Last Name:LESLIE-UNDERWOOD
Suffix:
Gender:
Credentials:MHC-LP, CASAC-2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 E 138TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10454-1932
Mailing Address - Country:US
Mailing Address - Phone:609-942-9479
Mailing Address - Fax:
Practice Address - Street 1:804 E 138TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10454-1932
Practice Address - Country:US
Practice Address - Phone:609-942-9479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-07
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP106105101YM0800X
NY13055101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty