Provider Demographics
NPI:1184768491
Name:LEISURE, TINA MARIE
Entity type:Individual
Prefix:DR
First Name:TINA
Middle Name:MARIE
Last Name:LEISURE
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 1:839 LARKMEAD RD
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-7579
Mailing Address - Country:US
Mailing Address - Phone:304-481-4526
Mailing Address - Fax:
Practice Address - Street 1:3 WESTERN HILLS DR
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26105-8122
Practice Address - Country:US
Practice Address - Phone:304-420-1395
Practice Address - Fax:304-420-1364
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV684103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810007824Medicaid
WV3810007824Medicaid