Provider Demographics
NPI:1245648898
Name:BOLDEN, LESLIE ANN (LSW)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANN
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:ANN
Other - Last Name:TERRIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 299
Mailing Address - Street 2:3389 WINFIELD RD
Mailing Address - City:WINFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:25213
Mailing Address - Country:US
Mailing Address - Phone:304-525-7851
Mailing Address - Fax:304-586-0671
Practice Address - Street 1:3375 US RT 60 E
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-0009
Practice Address - Country:US
Practice Address - Phone:304-525-7851
Practice Address - Fax:304-586-0671
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAD00939881104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0005355002Medicaid
WV9122342Medicare PIN