Provider Demographics
NPI:1265030530
Name:SELBY, LESLIE R (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:R
Last Name:SELBY
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 1:76 W JIMMIE LEEDS RD STE 305
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08205-9418
Mailing Address - Country:US
Mailing Address - Phone:609-573-5260
Mailing Address - Fax:
Practice Address - Street 1:76 W JIMMIE LEEDS RD STE 305
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-9418
Practice Address - Country:US
Practice Address - Phone:609-573-5260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC059453001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical