Healthcare Provider Details

I. General information

NPI: 1497267215
Provider Name (Legal Business Name): LESLIE K. ROBERTS MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2017
Last Update Date: 11/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 N. EDWARD STREET CIHA
DECATUR IL
62526
US

IV. Provider business mailing address

2300 N. EDWARD STREET CIHA
DECATUR IL
62526
US

V. Phone/Fax

Practice location:
  • Phone: 217-876-6438
  • Fax: 217-876-6485
Mailing address:
  • Phone: 217-876-6438
  • Fax: 217-876-6485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number150001221
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: