Provider Demographics
NPI:1477083715
Name:PENROD, LESLIE (LSW)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:PENROD
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 E WHEELING AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-2510
Mailing Address - Country:US
Mailing Address - Phone:740-432-1800
Mailing Address - Fax:740-432-9299
Practice Address - Street 1:1200 E WHEELING AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-2510
Practice Address - Country:US
Practice Address - Phone:740-432-1800
Practice Address - Fax:740-432-9299
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1101139101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2965468Medicaid