Provider Demographics
NPI:1619507324
Name:GLIDEWELL, LESLIE (MED)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:GLIDEWELL
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 COUNTY ROAD 375
Mailing Address - Street 2:
Mailing Address - City:BONO
Mailing Address - State:AR
Mailing Address - Zip Code:72416-7661
Mailing Address - Country:US
Mailing Address - Phone:870-926-9259
Mailing Address - Fax:
Practice Address - Street 1:260 COUNTY ROAD 375
Practice Address - Street 2:
Practice Address - City:BONO
Practice Address - State:AR
Practice Address - Zip Code:72416-7661
Practice Address - Country:US
Practice Address - Phone:870-926-9259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-22
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR237160790Medicaid