Provider Demographics
NPI:1659794469
Name:GODDARD, LESLIE KAREN (LICSW)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:KAREN
Last Name:GODDARD
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1593
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20725-1593
Mailing Address - Country:US
Mailing Address - Phone:301-300-2266
Mailing Address - Fax:240-294-7379
Practice Address - Street 1:8301 ASHFORD BLVD APT 720
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-5605
Practice Address - Country:US
Practice Address - Phone:301-300-2266
Practice Address - Fax:240-294-7379
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-30
Last Update Date:2020-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN68711041C0700X
VA09040106561041C0700X
MD196311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical