Provider Demographics
NPI:1770390775
Name:WOOD, LESLIE
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:WOOD
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 1:813 VARSITY DR STE 5
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4694
Mailing Address - Country:US
Mailing Address - Phone:662-840-2005
Mailing Address - Fax:662-840-2107
Practice Address - Street 1:813 VARSITY DR STE 5
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4694
Practice Address - Country:US
Practice Address - Phone:662-840-2005
Practice Address - Fax:662-840-2107
Is Sole Proprietor?:No
Enumeration Date:2024-12-12
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3201101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor