Provider Demographics
NPI:1932880481
Name:LESLIE, NATHAN R (MPSY)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:R
Last Name:LESLIE
Suffix:
Gender:M
Credentials:MPSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 QUAKER HILL DR APT 3
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-4702
Mailing Address - Country:US
Mailing Address - Phone:303-908-2555
Mailing Address - Fax:
Practice Address - Street 1:1190 WINTERSON RD STE 160
Practice Address - Street 2:
Practice Address - City:LINTHICUM HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:21090-2245
Practice Address - Country:US
Practice Address - Phone:303-908-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAO811103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist