MEDICARE: LESLEY BRODIE, M.D., P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center	042.0012150	VT
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center	042.0012150	VT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

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

Provider Business Mailing Address
First Line	:	PO BOX 766
Second Line	:
City	:	MANCHESTER
State	:	VT
Zip	:	05254-0766
Country	:	US
Telephone Number	:	802-367-1068
Fax Number	:	802-367-1069

Provider Business Practice Location Address
First Line	:	82 ELM STREET
Second Line	:
City	:	MANCHESTER CENTER
State	:	VT
Zip	:	05255-9642
Country	:	US
Telephone Number	:	802-367-1068
Fax Number	:	802-367-1069

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

Provider Enumeration Date	:	04/25/2014
Last Update Date	:	04/25/2014

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