MEDICARE: LESLIE PHILLOS DUCKETT LPC, NCC

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	101YP2500X	Professional Counselor	LPC010687	GA

General Provider Information

NPI Number	:	1336755537
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE PHILLOS DUCKETT LPC, NCC

Provider Business Mailing Address
First Line	:	6750 POLO DR
Second Line	:
City	:	CUMMING
State	:	GA
Zip	:	30040-5725
Country	:	US
Telephone Number	:	404-403-5690
Fax Number	:

Provider Business Practice Location Address
First Line	:	208 RIVER PARK NORTH DR
Second Line	:
City	:	WOODSTOCK
State	:	GA
Zip	:	30188-7834
Country	:	US
Telephone Number	:	404-307-9071
Fax Number	:

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

Provider Enumeration Date	:	09/22/2020
Last Update Date	:	09/22/2020

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