Provider Demographics
NPI:1922546175
Name:MAVROMATIS, LESLIE D (LICSW)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:D
Last Name:MAVROMATIS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9008
Mailing Address - Country:US
Mailing Address - Phone:304-933-3885
Mailing Address - Fax:304-933-3887
Practice Address - Street 1:527 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9008
Practice Address - Country:US
Practice Address - Phone:304-933-3885
Practice Address - Fax:304-933-3887
Is Sole Proprietor?:No
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP00944782101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health