Provider Demographics
NPI:1215421623
Name:LESLIE, RAY EDWARD
Entity type:Individual
Prefix:
First Name:RAY
Middle Name:EDWARD
Last Name:LESLIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 LOCUST ST APT 12B
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-4208
Mailing Address - Country:US
Mailing Address - Phone:201-264-4253
Mailing Address - Fax:
Practice Address - Street 1:100 E LEHIGH AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-1012
Practice Address - Country:US
Practice Address - Phone:215-707-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT2166572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry