Provider Demographics
NPI:1942213640
Name:FULLER, LESLIE ALAINE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:ALAINE
Last Name:FULLER
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 1:1030 JEFFERSON AVE 614/116A3
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-2193
Mailing Address - Country:US
Mailing Address - Phone:901-523-8990
Mailing Address - Fax:901-577-7518
Practice Address - Street 1:1030 JEFFERSON AVE 614/116A3
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2193
Practice Address - Country:US
Practice Address - Phone:901-523-8990
Practice Address - Fax:901-577-7518
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000002001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical