Provider Demographics
NPI:1457928426
Name:GREEN, LESLIE JEAN
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:JEAN
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 1:13765 VINTAGE DR SW
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98367-7391
Mailing Address - Country:US
Mailing Address - Phone:253-970-2414
Mailing Address - Fax:360-207-3986
Practice Address - Street 1:13765 VINTAGE DR SW
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98367-7391
Practice Address - Country:US
Practice Address - Phone:253-970-2414
Practice Address - Fax:360-207-3986
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WABACB689271106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician