Provider Demographics
NPI:1184858748
Name:DIETER, LESLIE ANNE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANNE
Last Name:DIETER
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 1:224 E LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:CHARLES TOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25414-1824
Mailing Address - Country:US
Mailing Address - Phone:540-931-2130
Mailing Address - Fax:
Practice Address - Street 1:224 E LIBERTY ST
Practice Address - Street 2:
Practice Address - City:CHARLES TOWN
Practice Address - State:WV
Practice Address - Zip Code:25414-1824
Practice Address - Country:US
Practice Address - Phone:540-931-2130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-12
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP029433681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810018805Medicaid