Healthcare Provider Details

I. General information

NPI: 1265009302
Provider Name (Legal Business Name): DONTE LESHON BERNARD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2021
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 S 8TH ST
COLUMBIA MO
65211-8908
US

IV. Provider business mailing address

PO BOX 843966
KANSAS CITY MO
64184-3966
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-4677
  • Fax: 573-882-4583
Mailing address:
  • Phone: 573-884-3300
  • Fax: 573-884-0943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number1651
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2022036658
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: