Basic Information
| Provider Information | |||||||||
| NPI: | 1285759191 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANTOINE | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3098 ANN ST | ||||||||
| Address2: | |||||||||
| City: | BALDWIN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115104504 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 8045 WINCHESTER BLVD | ||||||||
| Address2: | |||||||||
| City: | QUEENS VILLAGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114272193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184647500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 158150 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 158150 | 05 | NY | MEDICAID |