Provider Demographics
NPI:1023553880
Name:WHITE, LESLIE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:WHITE
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 1:18400 CHERRY CREEK DR
Mailing Address - Street 2:UNIT 401
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-2928
Mailing Address - Country:US
Mailing Address - Phone:708-821-3012
Mailing Address - Fax:
Practice Address - Street 1:18400 CHERRY CREEK DR
Practice Address - Street 2:401
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-2928
Practice Address - Country:US
Practice Address - Phone:708-821-3012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-03
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician