Basic Information
| Provider Information | |||||||||
| NPI: | 1932732351 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BECERRA | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 SHEEP SPRINGS WAYS | ||||||||
| Address2: | PO BOX 279 | ||||||||
| City: | JEMEZ PUEBLO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870240279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5758347258 | ||||||||
| FaxNumber: | 5758349507 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 MARBLE AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871062058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052722800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2020 | ||||||||
| LastUpdateDate: | 10/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PSY1542 | NM | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.