Provider Demographics
NPI:1295830297
Name:REAMBEAULT, LESLIE DIANE (MSW)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:DIANE
Last Name:REAMBEAULT
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5115 N RAVENSWOOD AVE
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2712
Mailing Address - Country:US
Mailing Address - Phone:773-230-5109
Mailing Address - Fax:773-275-1494
Practice Address - Street 1:5115 N RAVENSWOOD AVE
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2712
Practice Address - Country:US
Practice Address - Phone:773-230-5109
Practice Address - Fax:773-275-1494
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490089061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL021185OtherVMC
IL01627003OtherBCBS IL
IL595790Medicare ID - Type Unspecified