Basic Information
| Provider Information | |||||||||
| NPI: | 1730284951 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LESLIE | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 939 | ||||||||
| Address2: | |||||||||
| City: | BOLIVAR | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656130939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173286342 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 104 S. OHIO | ||||||||
| Address2: | |||||||||
| City: | HUMANSVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177542223 | ||||||||
| FaxNumber: | 4177548046 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 03/11/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 002386 | MO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | NONE AVAILABLE | 01 | MO | NONE AVAILABLE | OTHER |