Basic Information
| Provider Information | |||||||||
| NPI: | 1194968818 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DREW | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | ROOT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROOT | ||||||||
| OtherFirstName: | LESLIE | ||||||||
| OtherMiddleName: | P | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PH.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2495 SHREVEPORT HWY # 71 | ||||||||
| Address2: | |||||||||
| City: | PINEVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 713604044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184662589 | ||||||||
| FaxNumber: | 3184664468 | ||||||||
| Practice Location | |||||||||
| Address1: | 2495 SHREVEPORT HWY # 71 | ||||||||
| Address2: | |||||||||
| City: | PINEVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 713604044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184662589 | ||||||||
| FaxNumber: | 3184664468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2009 | ||||||||
| LastUpdateDate: | 10/22/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 33-516 | MS | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.