Provider Demographics
NPI:1700070844
Name:BRODY, LESLIE HANNAH (LISW-S, LICDC)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:HANNAH
Last Name:BRODY
Suffix:
Gender:F
Credentials:LISW-S, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4464 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45005-5464
Mailing Address - Country:US
Mailing Address - Phone:513-649-8008
Mailing Address - Fax:513-649-8004
Practice Address - Street 1:4464 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45005-5464
Practice Address - Country:US
Practice Address - Phone:513-649-8008
Practice Address - Fax:513-649-8004
Is Sole Proprietor?:No
Enumeration Date:2007-08-31
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI 0009280101YM0800X, 101YP2500X
OHI-00092801041C0700X
OHLICDC.011170101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH01-0693OtherCARF CERTIFICATION
OHH291160OtherMEDICARE INDIVIDUAL PTAN
OH0074946OtherMEDICAID LEGACY NUMBER MENTAL HEALTH
OH0074861OtherMEDICAID LEGACY NUMBER CHEMICAL DEPENDENCY