Provider Demographics
NPI:1841353000
Name:LIBERTINE, LESLIE ANN (MA MED LMHC)
Entity type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:ANN
Last Name:LIBERTINE
Suffix:
Gender:F
Credentials:MA MED LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 BRADFORD COMMONS LN
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184
Mailing Address - Country:US
Mailing Address - Phone:781-843-2846
Mailing Address - Fax:
Practice Address - Street 1:37 BELMONT ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301
Practice Address - Country:US
Practice Address - Phone:508-580-4691
Practice Address - Fax:508-588-5751
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5515101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health