Healthcare Provider Details

I. General information

NPI: 1124323969
Provider Name (Legal Business Name): LESLEY JAMES HEAD LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2011
Last Update Date: 03/02/2020
Certification Date: 03/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5819 WINDING LN STE 133
HIXSON TN
37343-4067
US

IV. Provider business mailing address

1103 E DALLAS RD APT 30
CHATTANOOGA TN
37405-2336
US

V. Phone/Fax

Practice location:
  • Phone: 423-933-2575
  • Fax: 423-285-6160
Mailing address:
  • Phone: 415-999-4630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6268
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: