Provider Demographics
NPI:1710104559
Name:DOUGLASS, LESLIE AS (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:AS
Last Name:DOUGLASS
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 1:6626 E 75TH STREET
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:317-621-7561
Mailing Address - Fax:317-355-6096
Practice Address - Street 1:322 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-4622
Practice Address - Country:US
Practice Address - Phone:765-453-8555
Practice Address - Fax:765-453-8020
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005269A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ2504001Medicare PIN