Provider Demographics
NPI:1174784862
Name:TESTER, LESLIE RAE
Entity type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:RAE
Last Name:TESTER
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 1:2800 HORSESHOE WAY
Mailing Address - Street 2:
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705-6121
Mailing Address - Country:US
Mailing Address - Phone:907-488-1017
Mailing Address - Fax:
Practice Address - Street 1:1825 MARIKA RD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-5521
Practice Address - Country:US
Practice Address - Phone:907-474-0890
Practice Address - Fax:907-474-3621
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-24
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
AK115111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker