Provider Demographics
NPI:1073403150
Name:CONRAD, LESLEY
Entity type:Individual
Prefix:
First Name:LESLEY
Middle Name:
Last Name:CONRAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17824 PALMETTO PASS LN
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33982-5158
Mailing Address - Country:US
Mailing Address - Phone:917-716-2296
Mailing Address - Fax:
Practice Address - Street 1:3331 E RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-1457
Practice Address - Country:US
Practice Address - Phone:239-737-1932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-08
Last Update Date:2025-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH26960101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health