Basic Information
| Provider Information | |||||||||
| NPI: | 1669605010 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSHOT | ||||||||
| FirstName: | LESLY | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PSY.D., BCBA-D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26901 BEAUMONT BLVD | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480333849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9475221867 | ||||||||
| FaxNumber: | 9475220307 | ||||||||
| Practice Location | |||||||||
| Address1: | 30503 GREENFIELD RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480761594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486914744 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2009 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TM1800X | 6301014875 | MI | N | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities | 103TC2200X | 6301014875 | MI | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.