Provider Demographics
NPI:1760690697
Name:NOLEN, LESLIE CLIFFORD JR (PHD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:CLIFFORD
Last Name:NOLEN
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 PRINCETON WOOD COVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-1907
Mailing Address - Country:US
Mailing Address - Phone:901-685-5380
Mailing Address - Fax:
Practice Address - Street 1:4758 EASLEY
Practice Address - Street 2:
Practice Address - City:MILLINGTON
Practice Address - State:TN
Practice Address - Zip Code:38053-1954
Practice Address - Country:US
Practice Address - Phone:901-873-2448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000000954103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical