Provider Demographics
NPI:1164614921
Name:GALVAN, LESLIE ELAINE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:ELAINE
Last Name:GALVAN
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 1:111 MARBLE
Mailing Address - Street 2:111 MARBLE DRIVE
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076
Mailing Address - Country:US
Mailing Address - Phone:501-952-9466
Mailing Address - Fax:
Practice Address - Street 1:111 MARBLE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-4971
Practice Address - Country:US
Practice Address - Phone:501-952-9466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-15
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1977-M104100000X
AR2425-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116399726Medicaid