Provider Demographics
NPI:1437492501
Name:JOHNSON, LESLIE BLACK (MA, LCMHC)
Entity type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:BLACK
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA, LCMHC
Other - Prefix:MS
Other - First Name:LESLIE
Other - Middle Name:ELIZABETH
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LCMHC
Mailing Address - Street 1:3912 BOROUGH RD
Mailing Address - Street 2:
Mailing Address - City:CURRIE
Mailing Address - State:NC
Mailing Address - Zip Code:28435-5752
Mailing Address - Country:US
Mailing Address - Phone:910-523-7418
Mailing Address - Fax:
Practice Address - Street 1:432 EASTWOOD RD STE 1A
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-1872
Practice Address - Country:US
Practice Address - Phone:910-523-7418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-27
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA10085101YP2500X
NC10085101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional