Provider Demographics
NPI:1699017780
Name:WYATT, LESLIE ANN (MED)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:ANN
Last Name:WYATT
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28012-3233
Mailing Address - Country:US
Mailing Address - Phone:704-747-4349
Mailing Address - Fax:
Practice Address - Street 1:52 MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:NC
Practice Address - Zip Code:28012-3233
Practice Address - Country:US
Practice Address - Phone:704-747-4349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-26
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA8736101YM0800X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No251S00000XAgenciesCommunity/Behavioral Health