Provider Demographics
NPI:1447576301
Name:DECKTER, LESLIE ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:ANN
Last Name:DECKTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4075 OLD WESTERN ROW RD
Mailing Address - Street 2:MLC 2047
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-3104
Mailing Address - Country:US
Mailing Address - Phone:513-536-4673
Mailing Address - Fax:513-536-0619
Practice Address - Street 1:4075 OLD WESTERN ROW RD
Practice Address - Street 2:MLC 2047
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-3104
Practice Address - Country:US
Practice Address - Phone:513-536-4673
Practice Address - Fax:513-536-0619
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-15
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35.1203882084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0119954Medicaid