Provider Demographics
NPI:1619250180
Name:FORD, LESLIE LEWIS (PHD LCSW)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:LEWIS
Last Name:FORD
Suffix:
Gender:F
Credentials:PHD LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 W BOUGHTON RD # 166
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1508
Mailing Address - Country:US
Mailing Address - Phone:312-399-3077
Mailing Address - Fax:
Practice Address - Street 1:5950 E LINCOLN AVE STE 300
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-3387
Practice Address - Country:US
Practice Address - Phone:312-399-3077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0115281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical