Provider Demographics
NPI:1154731958
Name:SMITH, LESLIE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:ROBISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1906 S LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-2429
Mailing Address - Country:US
Mailing Address - Phone:417-459-7247
Mailing Address - Fax:
Practice Address - Street 1:1906 S LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-2429
Practice Address - Country:US
Practice Address - Phone:417-459-7247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-01
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20140093971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1154731958Medicaid
MO1154731958Medicaid