Provider Demographics
NPI:1659558880
Name:BENNETT, LESLIE LYNN (LCSW)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:LYNN
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3371 KNICKERBOCKER RD # 203
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-6814
Mailing Address - Country:US
Mailing Address - Phone:325-221-4079
Mailing Address - Fax:325-227-4157
Practice Address - Street 1:2102 PECOS ST STE 10
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-3061
Practice Address - Country:US
Practice Address - Phone:325-221-4079
Practice Address - Fax:325-227-4157
Is Sole Proprietor?:No
Enumeration Date:2008-01-30
Last Update Date:2020-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
TX672931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX005282OtherBCBS
TX395401902Medicaid
TX832244OtherMEDICARE