Provider Demographics
NPI:1962009605
Name:GREEN, LESLYNNE LEE
Entity Type:Individual
Prefix:
First Name:LESLYNNE
Middle Name:LEE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561-4173
Mailing Address - Country:US
Mailing Address - Phone:850-503-0386
Mailing Address - Fax:
Practice Address - Street 1:2990 GULF BREEZE PKWY / COUNSELING SUITE
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32563-3256
Practice Address - Country:US
Practice Address - Phone:850-503-0386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH19381101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health