Provider Demographics
NPI:1316985088
Name:LESLIE AS DOUGLASS LICENSED CLINICAL SOCIAL WORKER LLC
Entity type:Organization
Organization Name:LESLIE AS DOUGLASS LICENSED CLINICAL SOCIAL WORKER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:AS
Authorized Official - Last Name:DOUGLASS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:765-357-8118
Mailing Address - Street 1:PO BOX 397
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IN
Mailing Address - Zip Code:46041-0397
Mailing Address - Country:US
Mailing Address - Phone:765-357-8118
Mailing Address - Fax:765-766-4241
Practice Address - Street 1:55 W. WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IN
Practice Address - Zip Code:46041-1923
Practice Address - Country:US
Practice Address - Phone:765-357-8118
Practice Address - Fax:765-766-4241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33003543A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200461950Medicaid