Provider Demographics
NPI:1568984664
Name:LESLIE, ANDIE MAIKA (PHD)
Entity type:Individual
Prefix:DR
First Name:ANDIE
Middle Name:MAIKA
Last Name:LESLIE
Suffix:
Gender:X
Credentials:PHD
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 2077
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-2077
Mailing Address - Country:US
Mailing Address - Phone:707-467-2010
Mailing Address - Fax:
Practice Address - Street 1:516 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-5410
Practice Address - Country:US
Practice Address - Phone:707-961-0308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-10
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB94027727103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical