Healthcare Provider Details

I. General information

NPI: 1629573001
Provider Name (Legal Business Name): LESLIE ELIZABETH SHEPHARD LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 03/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41641 N RIDGE RD
ELYRIA OH
44035-1264
US

IV. Provider business mailing address

3952 E 177TH ST
CLEVELAND OH
44128-1733
US

V. Phone/Fax

Practice location:
  • Phone: 440-324-7406
  • Fax:
Mailing address:
  • Phone: 216-256-7388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberS.1701719
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: