Provider Demographics
NPI:1194709519
Name:ANNIS, S. LESLIE (LCSW)
Entity type:Individual
Prefix:MS
First Name:S.
Middle Name:LESLIE
Last Name:ANNIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2904 203RD ST
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-2336
Mailing Address - Country:US
Mailing Address - Phone:718-361-2748
Mailing Address - Fax:718-732-2880
Practice Address - Street 1:2904 203RD ST
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11360-2336
Practice Address - Country:US
Practice Address - Phone:718-631-2748
Practice Address - Fax:718-732-2880
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYLCSWR 027552-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01988105Medicaid
NY01988105Medicaid
NYR28018Medicare UPIN