Basic Information
| Provider Information | |||||||||
| NPI: | 1174031561 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBERTSON | ||||||||
| FirstName: | LESLIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4020 FOLKER ST | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995085321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075631000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 926 ASPEN ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997095501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075631000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2018 | ||||||||
| LastUpdateDate: | 07/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 178.004356 | IL | N | Behavioral Health & Social Service Providers | Counselor | Professional | 221700000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Art Therapist | 101YP2500X | 129763 | AK | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.