Provider Demographics
NPI:1699283812
Name:ICENHOUR, LESLEY BLAIR (MSW, LCSWA)
Entity type:Individual
Prefix:
First Name:LESLEY
Middle Name:BLAIR
Last Name:ICENHOUR
Suffix:
Gender:F
Credentials:MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 NC HIGHWAY 18 S
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NC
Mailing Address - Zip Code:28675-8478
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1650 NC HIGHWAY 18 S
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NC
Practice Address - Zip Code:28675-8478
Practice Address - Country:US
Practice Address - Phone:336-372-4095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0121831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical