Provider Demographics
NPI:1750567301
Name:SACKETT, LESLIE A (LCSW)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:SACKETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 EDISON RD
Mailing Address - Street 2:STE A
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46637-5600
Mailing Address - Country:US
Mailing Address - Phone:574-287-3223
Mailing Address - Fax:574-287-1667
Practice Address - Street 1:2025 EDISON RD
Practice Address - Street 2:STE A
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46637-5600
Practice Address - Country:US
Practice Address - Phone:574-287-3223
Practice Address - Fax:574-287-1667
Is Sole Proprietor?:No
Enumeration Date:2008-01-14
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004612A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical