Provider Demographics
NPI:1992877922
Name:MALLIMSON, LESLIE (LPC)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:MALLIMSON
Suffix:
Gender:F
Credentials: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 182
Mailing Address - Street 2:68 MAIN ST
Mailing Address - City:CENTERBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06409
Mailing Address - Country:US
Mailing Address - Phone:860-767-2266
Mailing Address - Fax:860-767-5067
Practice Address - Street 1:68 MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTERBROOK
Practice Address - State:CT
Practice Address - Zip Code:06409
Practice Address - Country:US
Practice Address - Phone:860-767-2266
Practice Address - Fax:860-767-5067
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT000274CT101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional