Healthcare Provider Details

I. General information

NPI: 1033211321
Provider Name (Legal Business Name): LESLIE R JUSTICE DNP, PMHCNS-BC, APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. MARY L DIAS

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1278 NORTH LAFAYETTE DRIVE
SUMTER SC
29150-2964
US

IV. Provider business mailing address

1278 NORTH LAFAYETTE DRIVE
SUMTER SC
29150-2964
US

V. Phone/Fax

Practice location:
  • Phone: 803-774-4500
  • Fax: 803-774-4650
Mailing address:
  • Phone: 803-774-4500
  • Fax: 803-774-4628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number2210
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: