Healthcare Provider Details

I. General information

NPI: 1255254777
Provider Name (Legal Business Name): LESLIE T KIMBROUGH JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2026
Last Update Date: 08/01/2026
Certification Date: 08/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8090 WALNUT RUN RD
CORDOVA TN
38018-6362
US

IV. Provider business mailing address

8219 TOWN N COUNTRY DR
CORDOVA TN
38016-8584
US

V. Phone/Fax

Practice location:
  • Phone: 901-831-0063
  • Fax:
Mailing address:
  • Phone: 901-831-0063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: