Provider Demographics
NPI:1639256233
Name:LESLIE, GINA M (PSYD)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:M
Last Name:LESLIE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 BERTLAND AVE APT 1237
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-6825
Mailing Address - Country:US
Mailing Address - Phone:573-397-2846
Mailing Address - Fax:
Practice Address - Street 1:2901 BERTLAND AVE APT 1237
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-6825
Practice Address - Country:US
Practice Address - Phone:573-397-2846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810008022103T00000X
TX38068103T00000X
MO2003030084103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO499012607Medicaid