Provider Demographics
NPI:1801543640
Name:SMITH, LESLIE R
Entity type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:R
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:R
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1645 GUM CREEK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188
Mailing Address - Country:US
Mailing Address - Phone:770-313-3604
Mailing Address - Fax:
Practice Address - Street 1:1645 GUM CREEK CIRCLE
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188
Practice Address - Country:US
Practice Address - Phone:770-313-3604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator