Provider Demographics
NPI:1104077007
Name:STAFF, LESLIE M (LCPC, LMHC)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:M
Last Name:STAFF
Suffix:
Gender:F
Credentials:LCPC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3368 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130-2612
Mailing Address - Country:US
Mailing Address - Phone:617-892-7827
Mailing Address - Fax:617-522-0348
Practice Address - Street 1:3368 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-2612
Practice Address - Country:US
Practice Address - Phone:617-892-7827
Practice Address - Fax:617-522-0348
Is Sole Proprietor?:No
Enumeration Date:2008-10-09
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL3442101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME433129599Medicaid
MA9066OtherLICENSED MENTAL HEALTH COUNSELOR LICENSE NUMBER
MECC3690OtherLICENSED CLINICAL PROFESSIONAL COUNSELOR LICENSE NUMBER