MEDICARE: DR. KEVIN S LESLIE PSY.D, L.C.D.C

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	103TA0400X	Addiction (Substance Use Disorder) Psychologist	10910	TX
2	103TF0200X	Forensic Psychologist		TX
3	103TP2701X	Group Psychotherapy Psychologist		TX
4	103T00000X	Psychologist		TX

General Provider Information

NPI Number	:	1396123097
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEVIN S LESLIE PSY.D, L.C.D.C

Provider Business Mailing Address
First Line	:	3230 FALL CREEK HWY
Second Line	:	SUITE 110
City	:	GRANBURY
State	:	TX
Zip	:	76049-7909
Country	:	US
Telephone Number	:	817-776-7003
Fax Number	:

Provider Business Practice Location Address
First Line	:	3230 FALL CREEK HWY
Second Line	:	SUITE 110
City	:	GRANBURY
State	:	TX
Zip	:	76049-7909
Country	:	US
Telephone Number	:	817-776-7003
Fax Number	:

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

Provider Enumeration Date	:	05/13/2015
Last Update Date	:	04/27/2018

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