Provider Demographics
NPI:1932791985
Name:DR. LESLIE LIBERTY
Entity Type:Organization
Organization Name:DR. LESLIE LIBERTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:LIBERTY
Authorized Official - Suffix:
Authorized Official - Credentials:DSW
Authorized Official - Phone:209-401-5741
Mailing Address - Street 1:PO BOX 4212
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-0212
Mailing Address - Country:US
Mailing Address - Phone:209-401-5741
Mailing Address - Fax:
Practice Address - Street 1:924 N YOSEMITE ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95203-2217
Practice Address - Country:US
Practice Address - Phone:209-401-5741
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCSW7173OtherBOARD OF BEHAVIORAL SCIENCES