Basic Information
| Provider Information | |||||||||
| NPI: | 1497830285 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRINKERHOFF | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 S IRELAND BLVD | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449062223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195294124 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 270 STERKEL BLVD | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449071508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197561133 | ||||||||
| FaxNumber: | 4197566544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| 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 | 103TC0700X | 4598 | OH | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 000000207517 | 01 | OH | ANTHEM | OTHER |