Basic Information
| Provider Information | |||||||||
| NPI: | 1275000416 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUCE | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | FENNO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FENNO | ||||||||
| OtherFirstName: | LESLIE | ||||||||
| OtherMiddleName: | CAROL | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7307 HARVEST LN | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224077447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036063663 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7969 ASHTON AVE | ||||||||
| Address2: | |||||||||
| City: | MANASSAS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201092885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037927800 | ||||||||
| FaxNumber: | 7037925699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2018 | ||||||||
| LastUpdateDate: | 10/25/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 0701007918 | VA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.