Healthcare Provider Details

I. General information

NPI: 1033820949
Provider Name (Legal Business Name): LESLIE ANNE DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2022
Last Update Date: 12/12/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8134 8TH AVE LOT #16
NEW AUBURN MN
55366-0032
US

IV. Provider business mailing address

1720 2ND AVE S SDB BOX 99
BIRMINGHAM AL
35294-0007
US

V. Phone/Fax

Practice location:
  • Phone: 320-296-6325
  • Fax:
Mailing address:
  • Phone: 205-934-7016
  • Fax: 205-934-7013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: