Provider Demographics
NPI:1629441944
Name:BASHIOUM, LESLIE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:BASHIOUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:BATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:1443 KNIGHTSBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65706-7547
Mailing Address - Country:US
Mailing Address - Phone:417-612-3853
Mailing Address - Fax:
Practice Address - Street 1:4650 S NATIONAL AVE STE A4
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65810-2893
Practice Address - Country:US
Practice Address - Phone:417-208-9840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-09
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015034348101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1629441944Medicaid