Provider Demographics
NPI:1619371036
Name:LESLIE, MICHAEL JEREMY (BCABA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JEREMY
Last Name:LESLIE
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 N BELTLINE BLVD
Mailing Address - Street 2:APT 610E
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-3920
Mailing Address - Country:US
Mailing Address - Phone:803-834-9148
Mailing Address - Fax:
Practice Address - Street 1:2020 E HEBRON PKWY STE 120
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75007-1618
Practice Address - Country:US
Practice Address - Phone:469-892-7500
Practice Address - Fax:469-575-3002
Is Sole Proprietor?:No
Enumeration Date:2014-10-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
SC0-14-6176103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst