Healthcare Provider Details

I. General information

NPI: 1831587385
Provider Name (Legal Business Name): LESLIE ALLYN BIRDWHISTELL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2015
Last Update Date: 09/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 W PROFESSIONAL PARK CT SUITE 1
BOWLING GREEN KY
42104
US

IV. Provider business mailing address

1321 MURFRESBORO PIKE STE 702
NASHVILLE TN
37217-2679
US

V. Phone/Fax

Practice location:
  • Phone: 270-843-5300
  • Fax: 270-843-5383
Mailing address:
  • Phone: 615-724-4706
  • Fax: 615-577-5654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number164384
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3979
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: