Provider Demographics
NPI:1477158814
Name:KIRCH, LESLEY A
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:A
Last Name:KIRCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94205A HOLDENBURY DR
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13603-3268
Mailing Address - Country:US
Mailing Address - Phone:419-605-7452
Mailing Address - Fax:
Practice Address - Street 1:595 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1381
Practice Address - Country:US
Practice Address - Phone:315-788-1530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104342-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical