Healthcare Provider Details

I. General information

NPI: 1891009411
Provider Name (Legal Business Name): LESLIE JEAN BOULETTE MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2010
Last Update Date: 07/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 MAIN ST
SOUTHBRIDGE MA
01550-3727
US

IV. Provider business mailing address

328 MAIN ST
SOUTHBRIDGE MA
01550-3727
US

V. Phone/Fax

Practice location:
  • Phone: 508-765-9101
  • Fax: 508-764-4389
Mailing address:
  • Phone: 508-765-9101
  • Fax: 508-764-4389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: