Provider Demographics
NPI:1952546202
Name:LANG, LESLIE ELLIS (LMFT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:ELLIS
Last Name:LANG
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14041 ICOT BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33760-3702
Mailing Address - Country:US
Mailing Address - Phone:727-479-1800
Mailing Address - Fax:727-479-1248
Practice Address - Street 1:14041 ICOT BLVD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33760-3702
Practice Address - Country:US
Practice Address - Phone:727-479-1800
Practice Address - Fax:727-479-1248
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-15
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT 1131106H00000X
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL760308800Medicaid