Provider Demographics
NPI:1104114198
Name:OWEN, LESLIE JOHNSON (LPC)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:JOHNSON
Last Name:OWEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MRS
Other - First Name:LESLIE
Other - Middle Name:JOHNSON
Other - Last Name:HUGHES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:3711 EXECUTIVE CENTER DR.
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907
Mailing Address - Country:US
Mailing Address - Phone:706-210-8855
Mailing Address - Fax:678-541-7699
Practice Address - Street 1:1202 TOWN PARK LN STE 300
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3477
Practice Address - Country:US
Practice Address - Phone:706-210-8855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-12
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008165101YP2500X
KY1234101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health