Provider Demographics
NPI:1417171299
Name:PARKS, LESLIE GOINS (MED, LPC)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:GOINS
Last Name:PARKS
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8344 LAUREL RUN DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-6188
Mailing Address - Country:US
Mailing Address - Phone:704-608-9377
Mailing Address - Fax:
Practice Address - Street 1:769 N WENDOVER RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211
Practice Address - Country:US
Practice Address - Phone:704-376-7180
Practice Address - Fax:704-531-9266
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4662101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102691Medicaid