Provider Demographics
NPI:1134259443
Name:SELF FORD, LESLEY (LPC)
Entity type:Individual
Prefix:
First Name:LESLEY
Middle Name:
Last Name:SELF FORD
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:LESLEY
Other - Middle Name:
Other - Last Name:FORD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 115
Mailing Address - Street 2:
Mailing Address - City:IVAN
Mailing Address - State:AR
Mailing Address - Zip Code:71748-0115
Mailing Address - Country:US
Mailing Address - Phone:501-837-5773
Mailing Address - Fax:870-352-0223
Practice Address - Street 1:201 N CLIFTON ST
Practice Address - Street 2:
Practice Address - City:FORDYCE
Practice Address - State:AR
Practice Address - Zip Code:71742-3026
Practice Address - Country:US
Practice Address - Phone:870-352-6311
Practice Address - Fax:870-352-0223
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1808119101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health