Healthcare Provider Details

I. General information

NPI: 1346226222
Provider Name (Legal Business Name): LESLIE F DIMELLA PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 05/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

374 GRAND AVE FAIR HAVEN COMMUNITY HEALTH CENTER
NEW HAVEN CT
06513-3733
US

IV. Provider business mailing address

210 MILLBROOK RD
NORTH HAVEN CT
06473-4336
US

V. Phone/Fax

Practice location:
  • Phone: 203-777-7411
  • Fax:
Mailing address:
  • Phone: 203-507-2036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number003109
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: