Provider Demographics
NPI:1841339033
Name:ELLENBOGEN, LESLIE ANN (LCSW-ACP)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANN
Last Name:ELLENBOGEN
Suffix:
Gender:F
Credentials:LCSW-ACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8623 STARCREST DR APT W3
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-4706
Mailing Address - Country:US
Mailing Address - Phone:210-653-4135
Mailing Address - Fax:210-590-7911
Practice Address - Street 1:8623 STARCREST DR APT W3
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-4706
Practice Address - Country:US
Practice Address - Phone:210-653-4135
Practice Address - Fax:210-590-7911
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS123881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX060825OtherVALUE OPTIONS
TX00S89COtherBLUE CROSS BLUE SHIELD
TX86501QOtherBC BS ALPHA OMEGA
TX060825OtherVALUE OPTIONS