Provider Demographics
NPI:1588192165
Name:WHITE, LESLIE MICHELLE (EDS)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:MICHELLE
Last Name:WHITE
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7529
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-7481
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:374 GINGER DR
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-3746
Practice Address - Country:US
Practice Address - Phone:228-281-3160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-26
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS189601106E00000X, 171M00000X, 225800000X, 373H00000X, 405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No405300000XOther Service ProvidersPrevention Professional