Provider Demographics
NPI:1457783466
Name:MACKINNON, LESLIE PATE (LESLIE MACKINNON)
Entity type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:PATE
Last Name:MACKINNON
Suffix:
Gender:F
Credentials:LESLIE MACKINNON
Other - Prefix:MRS
Other - First Name:LESLIE
Other - Middle Name:PATE
Other - Last Name:MACKINNON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1836 WALTHALL DR NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-2647
Mailing Address - Country:US
Mailing Address - Phone:404-355-3887
Mailing Address - Fax:
Practice Address - Street 1:1836 WALTHALL DR NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-2647
Practice Address - Country:US
Practice Address - Phone:404-603-5335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0008171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical