Provider Demographics
NPI:1215049564
Name:WEITZEL-NICOLL, LESLIE (LCSW-C)
Entity type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:
Last Name:WEITZEL-NICOLL
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13583 DEER BROOK CT
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:MD
Mailing Address - Zip Code:21771-4569
Mailing Address - Country:US
Mailing Address - Phone:301-829-8626
Mailing Address - Fax:
Practice Address - Street 1:129 W PATRICK ST
Practice Address - Street 2:STE 13B
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-5682
Practice Address - Country:US
Practice Address - Phone:301-873-2348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD085421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX289SMedicare UPIN