Provider Demographics
NPI:1699054619
Name:GRAY, LESLIE ANN (LISW S)
Entity type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:ANN
Last Name:GRAY
Suffix:
Gender:F
Credentials:LISW S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26282 MALLARD AVE
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44132-1415
Mailing Address - Country:US
Mailing Address - Phone:216-269-9577
Mailing Address - Fax:
Practice Address - Street 1:34950 CHARDON RD BLDG II STE 210
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY HILLS
Practice Address - State:OH
Practice Address - Zip Code:44094-9162
Practice Address - Country:US
Practice Address - Phone:216-269-9577
Practice Address - Fax:954-208-9777
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-08
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI07000411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0253751Medicaid