Provider Demographics
NPI:1144373564
Name:GILL, LESLIE A (PHD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:A
Last Name:GILL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 FLOYD GOLDEN CIR
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-7031
Mailing Address - Country:US
Mailing Address - Phone:505-799-3553
Mailing Address - Fax:
Practice Address - Street 1:212 FLOYD GOLDEN CIR
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-7031
Practice Address - Country:US
Practice Address - Phone:505-799-3553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM299606103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM36686760Medicaid