Healthcare Provider Details

I. General information

NPI: 1013967702
Provider Name (Legal Business Name): LESLIE WITHERELL MSW, LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 INDIAN WOOD CIR STE 200
MAUMEE OH
43537-4055
US

IV. Provider business mailing address

2644 MEADOWWOOD DR
TOLEDO OH
43606-3063
US

V. Phone/Fax

Practice location:
  • Phone: 877-906-9699
  • Fax: 888-483-0118
Mailing address:
  • Phone: 419-367-8844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI 5445
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: