Provider Demographics
NPI:1508590860
Name:SHOCKEY, LESLIE RAE (PRSS)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:RAE
Last Name:SHOCKEY
Suffix:
Gender:F
Credentials:PRSS
Other - Prefix:MS
Other - First Name:LESLIE
Other - Middle Name:RAE
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 681
Mailing Address - Street 2:
Mailing Address - City:ANSTED
Mailing Address - State:WV
Mailing Address - Zip Code:25812-0681
Mailing Address - Country:US
Mailing Address - Phone:304-658-4062
Mailing Address - Fax:
Practice Address - Street 1:101 S EISENHOWER DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-4929
Practice Address - Country:US
Practice Address - Phone:304-256-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist