Provider Demographics
NPI:1114344330
Name:TEITELBAUM, LESLEY (PHD)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:
Last Name:TEITELBAUM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5080 BRIDLE PATH RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-9734
Mailing Address - Country:US
Mailing Address - Phone:315-663-6694
Mailing Address - Fax:
Practice Address - Street 1:5080 BRIDLE PATH RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-9734
Practice Address - Country:US
Practice Address - Phone:315-663-6694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist