Basic Information
| Provider Information | |||||||||
| NPI: | 1033211321 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUSTICE | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DNP, PMHCNS-BC, APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DIAS | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1278 NORTH LAFAYETTE DRIVE | ||||||||
| Address2: | |||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291502964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037744500 | ||||||||
| FaxNumber: | 8037744628 | ||||||||
| Practice Location | |||||||||
| Address1: | 1278 NORTH LAFAYETTE DRIVE | ||||||||
| Address2: | |||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291502964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037744500 | ||||||||
| FaxNumber: | 8037744650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2006 | ||||||||
| LastUpdateDate: | 10/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0808X | 2210 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | NP1471 | 05 | SC | MEDICAID |