Provider Demographics
NPI:1407472137
Name:PAGE, LESLIE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:PAGE
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:PAGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, CAC-AD
Mailing Address - Street 1:27 SHAWNEE CT APT 202
Mailing Address - Street 2:
Mailing Address - City:PARKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21234-8674
Mailing Address - Country:US
Mailing Address - Phone:443-469-2058
Mailing Address - Fax:
Practice Address - Street 1:27 SHAWNEE CT APT 202
Practice Address - Street 2:
Practice Address - City:PARKVILLE
Practice Address - State:MD
Practice Address - Zip Code:21234-8674
Practice Address - Country:US
Practice Address - Phone:443-469-2058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC2168101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)