MEDICARE: MR. LESLEY JAMES HEAD LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	6268	TN

General Provider Information

NPI Number	:	1124323969
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LESLEY JAMES HEAD LCSW

Provider Business Mailing Address
First Line	:	1103 E DALLAS RD APT 30
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37405-2336
Country	:	US
Telephone Number	:	415-999-4630
Fax Number	:

Provider Business Practice Location Address
First Line	:	5819 WINDING LN STE 133
Second Line	:
City	:	HIXSON
State	:	TN
Zip	:	37343-4067
Country	:	US
Telephone Number	:	423-933-2575
Fax Number	:	423-285-6160

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2011
Last Update Date	:	03/02/2020

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