Basic Information
| Provider Information | |||||||||
| NPI: | 1902348550 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURTON | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 RIVER RD | ||||||||
| Address2: | UNIT 305 | ||||||||
| City: | COS COB | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068072723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036372930 | ||||||||
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| Practice Location | |||||||||
| Address1: | GAYLORD FARM RD | ||||||||
| Address2: | GAYLORD HOSPITAL | ||||||||
| City: | WALLINGFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032842800 | ||||||||
| FaxNumber: | 2032943294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2016 | ||||||||
| LastUpdateDate: | 11/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 1456 | CT | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.