Basic Information
| Provider Information | |||||||||
| NPI: | 1669430237 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEYER | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | JOHNSON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA LP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | LESLIE | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3915 GOLDEN VALLEY ROAD | ||||||||
| Address2: | COURAGE CENTER | ||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635200493 | ||||||||
| FaxNumber: | 7635200355 | ||||||||
| Practice Location | |||||||||
| Address1: | 3915 GOLDEN VALLEY ROAD | ||||||||
| Address2: | COURAGE CENTER | ||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635200493 | ||||||||
| FaxNumber: | 7635200355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | LP3588 | MN | X | Behavioral Health & Social Service Providers | Psychologist | 103TR0400X | LP3588 | MN | X | Behavioral Health & Social Service Providers | Psychologist | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 151758 | 01 | U CARE | OTHER | 6267174 | 01 | UBH | OTHER | 6552200 | 01 | SOUTH DAKOTA MA | OTHER | 6269174 | 01 | MEDICA | OTHER | 63D67ME | 01 | BCBS MINNESOTA | OTHER | 963371019242 | 01 | PREFERRED ONE | OTHER | HP27751 | 01 | HEALTH PARTNERS | OTHER |