Provider Demographics
NPI:1124296280
Name:GUINAUGH SUPKOFF, LESLIE JANE (MFT)
Entity type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:JANE
Last Name:GUINAUGH SUPKOFF
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MS
Other - First Name:LESLIE
Other - Middle Name:JANE
Other - Last Name:GUINAUGH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MFT
Mailing Address - Street 1:251 N SWALL DR
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-1712
Mailing Address - Country:US
Mailing Address - Phone:310-271-7764
Mailing Address - Fax:
Practice Address - Street 1:554 S SAN VICENTE BLVD STE 102
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4652
Practice Address - Country:US
Practice Address - Phone:310-663-4244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MFC 30843101YM0800X
CAMFC 30843101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)