Provider Demographics
NPI:1194968818
Name:DREW, LESLIE ROOT (PHD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:ROOT
Last Name:DREW
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:LESLIE
Other - Middle Name:P
Other - Last Name:ROOT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:2495 SHREVEPORT HWY # 71
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-4044
Mailing Address - Country:US
Mailing Address - Phone:318-466-2589
Mailing Address - Fax:318-466-4468
Practice Address - Street 1:2495 SHREVEPORT HWY # 71
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-4044
Practice Address - Country:US
Practice Address - Phone:318-466-2589
Practice Address - Fax:318-466-4468
Is Sole Proprietor?:No
Enumeration Date:2009-04-10
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS33-516103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical