Provider Demographics
NPI:1285004358
Name:FLUENCE, LESLIE SOUTHALL
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:SOUTHALL
Last Name:FLUENCE
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 1:42151 STONE RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-6273
Mailing Address - Country:US
Mailing Address - Phone:225-572-8295
Mailing Address - Fax:
Practice Address - Street 1:239 EVANGELINE DR
Practice Address - Street 2:
Practice Address - City:DONALDSONVILLE
Practice Address - State:LA
Practice Address - Zip Code:70346-4374
Practice Address - Country:US
Practice Address - Phone:225-572-8295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
LA13397104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker