Provider Demographics
NPI:1164054771
Name:PHILLIPS, LESLIE NICOLE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:NICOLE
Last Name:PHILLIPS
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 1:415 N RICHARD JACKSON BLVD STE 202B
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407-3691
Mailing Address - Country:US
Mailing Address - Phone:850-866-0441
Mailing Address - Fax:850-710-0741
Practice Address - Street 1:1405 WEATHERLY PLZ SE STE E
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35803-2663
Practice Address - Country:US
Practice Address - Phone:256-600-0574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician