Basic Information
| Provider Information | |||||||||
| NPI: | 1699283812 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ICENHOUR | ||||||||
| FirstName: | LESLEY | ||||||||
| MiddleName: | BLAIR | ||||||||
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| Credential: | MSW, LCSWA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 NC HIGHWAY 18 S | ||||||||
| Address2: | |||||||||
| City: | SPARTA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286758478 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1650 NC HIGHWAY 18 S | ||||||||
| Address2: | |||||||||
| City: | SPARTA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286758478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363724095 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2018 | ||||||||
| LastUpdateDate: | 01/22/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | P012183 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.