Provider Demographics
NPI:1710314091
Name:PROVARD, LESLIE A (MA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:PROVARD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 TALLOW HILL RD
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17202-7653
Mailing Address - Country:US
Mailing Address - Phone:717-552-3494
Mailing Address - Fax:
Practice Address - Street 1:1331 S 7TH ST
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-4850
Practice Address - Country:US
Practice Address - Phone:717-262-2940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health