MEDICARE: LESLEY SELF FORD LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	A1808119	AR

General Provider Information

NPI Number	:	1134259443
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLEY SELF FORD LPC

Provider Business Mailing Address
First Line	:	PO BOX 115
Second Line	:
City	:	IVAN
State	:	AR
Zip	:	71748-0115
Country	:	US
Telephone Number	:	501-837-5773
Fax Number	:	870-352-0223

Provider Business Practice Location Address
First Line	:	201 N CLIFTON ST
Second Line	:
City	:	FORDYCE
State	:	AR
Zip	:	71742-3026
Country	:	US
Telephone Number	:	870-352-6311
Fax Number	:	870-352-0223

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	01/26/2024

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