Provider Demographics
NPI:1194932178
Name:FADEM, LESLIE KAREN (MA)
Entity type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:KAREN
Last Name:FADEM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3191
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91944-3191
Mailing Address - Country:US
Mailing Address - Phone:760-632-1670
Mailing Address - Fax:619-698-6605
Practice Address - Street 1:7284 PRINCETON AVE
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-4716
Practice Address - Country:US
Practice Address - Phone:619-698-6605
Practice Address - Fax:619-698-6605
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC27790106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist