Provider Demographics
NPI:1437293768
Name:TOOLE, LESLIE VAN (LMFT)
Entity Type:Individual
Prefix:MR
First Name:LESLIE
Middle Name:VAN
Last Name:TOOLE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 GREENVILLE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-3231
Mailing Address - Country:US
Mailing Address - Phone:706-884-0987
Mailing Address - Fax:706-884-9696
Practice Address - Street 1:321 GREENVILLE ST
Practice Address - Street 2:SUITE A
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241-3231
Practice Address - Country:US
Practice Address - Phone:706-884-0987
Practice Address - Fax:706-884-9696
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000733106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000733OtherSTATE LICENSE NUMBER