Healthcare Provider Details

I. General information

NPI: 1114347440
Provider Name (Legal Business Name): LESLEY BRODIE, M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2014
Last Update Date: 04/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82 ELM STREET
MANCHESTER CENTER VT
05255-9642
US

IV. Provider business mailing address

PO BOX 766
MANCHESTER VT
05254-0766
US

V. Phone/Fax

Practice location:
  • Phone: 802-367-1068
  • Fax: 802-367-1069
Mailing address:
  • Phone: 802-367-1068
  • Fax: 802-367-1069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number042.0012150
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number042.0012150
License Number StateVT

VIII. Authorized Official

Name: DR. LESLEY THOMPSON BRODIE
Title or Position: OFFICER/MEMBER
Credential: M.D.
Phone: 802-367-1068