Provider Demographics
NPI:1396123097
Name:LESLIE, KEVIN S (PSYD, LCDC)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:S
Last Name:LESLIE
Suffix:
Gender:M
Credentials:PSYD, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3230 FALL CREEK HWY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76049-7909
Mailing Address - Country:US
Mailing Address - Phone:817-776-7003
Mailing Address - Fax:
Practice Address - Street 1:3230 FALL CREEK HWY
Practice Address - Street 2:SUITE 110
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76049-7909
Practice Address - Country:US
Practice Address - Phone:817-776-7003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-13
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10910103TA0400X
TX103TF0200X, 103TP2701X, 103T00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist