Provider Demographics
NPI:1871262493
Name:LESLIE, TARA LEAH
Entity type:Individual
Prefix:MS
First Name:TARA
Middle Name:LEAH
Last Name:LESLIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-9715
Mailing Address - Country:US
Mailing Address - Phone:252-450-9244
Mailing Address - Fax:
Practice Address - Street 1:412 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-9715
Practice Address - Country:US
Practice Address - Phone:252-450-9244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities