Provider Demographics
NPI:1336604842
Name:PETRUK, LESLIE H (LPC)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:H
Last Name:PETRUK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:H
Other - Last Name:PETRUK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PEDULLA
Mailing Address - Street 1:1821 CUMBERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-6112
Mailing Address - Country:US
Mailing Address - Phone:704-665-0065
Mailing Address - Fax:
Practice Address - Street 1:1821 CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-6112
Practice Address - Country:US
Practice Address - Phone:704-665-0065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4290101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty