Provider Demographics
NPI:1265103188
Name:LESLIE, TAMARA (LPC)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:LESLIE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 CATIE LN SE
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-8324
Mailing Address - Country:US
Mailing Address - Phone:478-387-8370
Mailing Address - Fax:
Practice Address - Street 1:2450 VINSON HWY SE
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-4881
Practice Address - Country:US
Practice Address - Phone:478-387-8370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009079101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health