Healthcare Provider Details

I. General information

NPI: 1063801835
Provider Name (Legal Business Name): LESLIE BARTLETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2015
Last Update Date: 02/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4084 OKEMOS RD
OKEMOS MI
48864-3258
US

IV. Provider business mailing address

PO BOX 10
MASON MI
48854-0010
US

V. Phone/Fax

Practice location:
  • Phone: 517-347-4848
  • Fax:
Mailing address:
  • Phone: 517-676-9788
  • Fax: 517-676-3438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301011010
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: