Provider Demographics
NPI:1376695288
Name:BAILEY, LEISA ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:LEISA
Middle Name:ANN
Last Name:BAILEY
Suffix:
Gender:F
Credentials:PHD
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Mailing Address - Street 1:600 KENNESAW AVE NW
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-6988
Mailing Address - Country:US
Mailing Address - Phone:770-428-6698
Mailing Address - Fax:770-428-7475
Practice Address - Street 1:600 KENNESAW AVE NW
Practice Address - Street 2:SUITE 300
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-6988
Practice Address - Country:US
Practice Address - Phone:770-428-6698
Practice Address - Fax:770-428-7475
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-08-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA999103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000819OtherVALUE OPTIONS
GA000819OtherVALUE OPTIONS