Provider Demographics
NPI:1386083392
Name:MELLENBRUCH, LESLIE (MS, LPC)
Entity type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:
Last Name:MELLENBRUCH
Suffix:
Gender:F
Credentials:MS, LPC
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 1631
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:TX
Mailing Address - Zip Code:78602-8631
Mailing Address - Country:US
Mailing Address - Phone:512-924-8555
Mailing Address - Fax:
Practice Address - Street 1:944 HIGHWAY 71 E
Practice Address - Street 2:SUITE 110-1
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-5023
Practice Address - Country:US
Practice Address - Phone:512-924-8555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-24
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15878101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional