Provider Demographics
NPI:1023799509
Name:FITZWATER, LESLIE (LMSW)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:FITZWATER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:RHUDY, MCDANIEL, MOORE, FAIRFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2406
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-2406
Mailing Address - Country:US
Mailing Address - Phone:575-755-5555
Mailing Address - Fax:575-755-5556
Practice Address - Street 1:204 W 2ND ST STE 2
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4669
Practice Address - Country:US
Practice Address - Phone:575-755-5555
Practice Address - Fax:575-755-5556
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSWB20220948104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker