Basic Information
| Provider Information | |||||||||
| NPI: | 1104327006 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARMON | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1324 MAPLETON AVE | ||||||||
| Address2: | |||||||||
| City: | SUFFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060781383 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2257 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011071905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137333488 | ||||||||
| FaxNumber: | 4137317381 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2018 | ||||||||
| LastUpdateDate: | 02/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.