Provider Demographics
NPI:1124688890
Name:DONNER, LESLIE
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:DONNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:PAGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2204 KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-3242
Mailing Address - Country:US
Mailing Address - Phone:270-777-4490
Mailing Address - Fax:866-824-4022
Practice Address - Street 1:2204 KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3242
Practice Address - Country:US
Practice Address - Phone:270-777-4490
Practice Address - Fax:866-441-1083
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-16
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY115924103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service