Basic Information
| Provider Information | |||||||||
| NPI: | 1134504947 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2809 FOREST HOME RD | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724015320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669721268 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1106 POPLAR PL | ||||||||
| Address2: | |||||||||
| City: | ROGERS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727564249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4793726464 | ||||||||
| FaxNumber: | 4793426464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2015 | ||||||||
| LastUpdateDate: | 09/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | P1910123 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 236565719 | 05 | AR | MEDICAID |