Provider Demographics
NPI:1093005795
Name:QUACKENBUSH, LESLIE JEAN (LCSW)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:JEAN
Last Name:QUACKENBUSH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3495 PIEDMONT RD NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1717
Mailing Address - Country:US
Mailing Address - Phone:404-504-5678
Mailing Address - Fax:
Practice Address - Street 1:3650 STEVE REYNOLDS BLVD
Practice Address - Street 2:GWINNETT COMPREHENSIVE MEDICAL CENTER
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4506
Practice Address - Country:US
Practice Address - Phone:919-764-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-14
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0047741041C0700X
GACSW0053071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical