Basic Information
| Provider Information | |||||||||
| NPI: | 1316047111 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATKINS | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 207 FOOTE AVE | ||||||||
| Address2: | FINANCE DEPARTMENT | ||||||||
| City: | JAMESTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147017077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7164870141 | ||||||||
| FaxNumber: | 7164871802 | ||||||||
| Practice Location | |||||||||
| Address1: | 51 GLASGOW AVE | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147016413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7164870141 | ||||||||
| FaxNumber: | 7164871802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 02/24/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 073269-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 00618162 | 05 | NY | MEDICAID | 073269 | 01 | NY | LICENSE | OTHER |