Provider Demographics
NPI:1861987877
Name:LOGUE, LESLIE STAR
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:STAR
Last Name:LOGUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2252
Mailing Address - Street 2:
Mailing Address - City:OVERTON
Mailing Address - State:NV
Mailing Address - Zip Code:89040-2252
Mailing Address - Country:US
Mailing Address - Phone:214-683-8684
Mailing Address - Fax:
Practice Address - Street 1:408 S JONES BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-2658
Practice Address - Country:US
Practice Address - Phone:702-496-1367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-22
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst