MEDICARE: LESLIE VICTORIA KINNEY

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	106S00000X	Behavior Technician
2	171M00000X	Case Manager/Care Coordinator
3	101YA0400X	Addiction (Substance Use Disorder) Counselor	CDCA172698	OH

General Provider Information

NPI Number	:	1578044020
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE VICTORIA KINNEY

Provider Business Mailing Address
First Line	:	6400 E BROAD ST FL 4
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43213-2086
Country	:	US
Telephone Number	:	937-228-0579
Fax Number	:

Provider Business Practice Location Address
First Line	:	6400 E BROAD ST FL 4
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43213-2086
Country	:	US
Telephone Number	:	937-228-0579
Fax Number	:

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

Provider Enumeration Date	:	08/23/2018
Last Update Date	:	08/25/2021

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