Provider Demographics
NPI:1477727485
Name:ANDERSON, LESLIE LOCKETT (MAC LAC)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:LOCKETT
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MAC LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6362 RED HAVEN ROAD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045
Mailing Address - Country:US
Mailing Address - Phone:410-340-2618
Mailing Address - Fax:
Practice Address - Street 1:9170 RT 108
Practice Address - Street 2:SUITE 202
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045
Practice Address - Country:US
Practice Address - Phone:410-340-2618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01434171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist