Healthcare Provider Details

I. General information

NPI: 1700070844
Provider Name (Legal Business Name): LESLIE HANNAH BRODY LISW-S, LICDC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2007
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4464 S DIXIE HWY
MIDDLETOWN OH
45005-5464
US

IV. Provider business mailing address

4464 S DIXIE HWY
MIDDLETOWN OH
45005-5464
US

V. Phone/Fax

Practice location:
  • Phone: 513-649-8008
  • Fax: 513-649-8004
Mailing address:
  • Phone: 513-649-8008
  • Fax: 513-649-8004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberI 0009280
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberI 0009280
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-0009280
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.011170
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: