Provider Demographics
NPI:1801377932
Name:WEARLY, LESLIE NICOLE (SWA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:NICOLE
Last Name:WEARLY
Suffix:
Gender:F
Credentials:SWA
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:NICOLE
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SWA
Mailing Address - Street 1:530 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-1500
Mailing Address - Country:US
Mailing Address - Phone:419-221-1168
Mailing Address - Fax:
Practice Address - Street 1:1101 N VANDEMARK RD
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-3567
Practice Address - Country:US
Practice Address - Phone:937-492-8080
Practice Address - Fax:937-492-6971
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHW.0001539104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker