Provider Demographics
NPI:1396012639
Name:WHITE, LESLIE D (MED)
Entity Type:Individual
Prefix:MR
First Name:LESLIE
Middle Name:D
Last Name:WHITE
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 N BROADWAY ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-2538
Mailing Address - Country:US
Mailing Address - Phone:918-647-0485
Mailing Address - Fax:918-647-0571
Practice Address - Street 1:2104 N BROADWAY ST UNIT A
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2538
Practice Address - Country:US
Practice Address - Phone:918-647-0485
Practice Address - Fax:918-647-0571
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor