Healthcare Provider Details

I. General information

NPI: 1801911805
Provider Name (Legal Business Name): LESLIE GLAZER PH.D. LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 04/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 ELM ST
BENNINGTON VT
05201-2865
US

IV. Provider business mailing address

PO BOX 198
WEST PAWLET VT
05775-0198
US

V. Phone/Fax

Practice location:
  • Phone: 413-664-4541
  • Fax:
Mailing address:
  • Phone: 802-447-8554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number048-0000928
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: