Provider Demographics
NPI:1770909038
Name:SUGIUCHI, LESLIE
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:SUGIUCHI
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 1:2321 FAIRLESS DR
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44055-3516
Mailing Address - Country:US
Mailing Address - Phone:440-277-7263
Mailing Address - Fax:440-277-5566
Practice Address - Street 1:2321 FAIRLESS DR
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44055-3516
Practice Address - Country:US
Practice Address - Phone:440-277-7263
Practice Address - Fax:440-277-5566
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH103TS0200X103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool