Provider Demographics
NPI:1033211321
Name:JUSTICE, LESLIE R (DNP, PMHCNS-BC, APRN)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:R
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:DNP, PMHCNS-BC, APRN
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:L
Other - Last Name:DIAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1278 NORTH LAFAYETTE DRIVE
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-2964
Mailing Address - Country:US
Mailing Address - Phone:803-774-4500
Mailing Address - Fax:803-774-4628
Practice Address - Street 1:1278 NORTH LAFAYETTE DRIVE
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-2964
Practice Address - Country:US
Practice Address - Phone:803-774-4500
Practice Address - Fax:803-774-4650
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2210364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1471Medicaid
SCS800953353Medicare UPIN