=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407151947
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LESLIE WADE R.N., L.C.S.W.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2011
-----------------------------------------------------
Last Update Date | 01/13/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6501 ARMY PENTAGON CORRIDOR 8, ROOM MG886A.4
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20310-5801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-692-8887
-----------------------------------------------------
Fax | 703-692-6201
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1225 MARTHA CUSTIS DR #217
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22302-2017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-580-6289
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 34004939A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 28128139A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------