Provider Demographics
NPI:1679231252
Name:DUKES, LEISA
Entity Type:Individual
Prefix:
First Name:LEISA
Middle Name:
Last Name:DUKES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 CENTER DR
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-5213
Mailing Address - Country:US
Mailing Address - Phone:912-293-6329
Mailing Address - Fax:
Practice Address - Street 1:304 ARLINGTON DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8935
Practice Address - Country:US
Practice Address - Phone:912-537-1414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty