Provider Demographics
NPI:1114347440
Name:LESLEY BRODIE, M.D., P.C.
Entity Type:Organization
Organization Name:LESLEY BRODIE, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLEY
Authorized Official - Middle Name:THOMPSON
Authorized Official - Last Name:BRODIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-367-1068
Mailing Address - Street 1:PO BOX 766
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05254-0766
Mailing Address - Country:US
Mailing Address - Phone:802-367-1068
Mailing Address - Fax:802-367-1069
Practice Address - Street 1:82 ELM STREET
Practice Address - Street 2:
Practice Address - City:MANCHESTER CENTER
Practice Address - State:VT
Practice Address - Zip Code:05255-9642
Practice Address - Country:US
Practice Address - Phone:802-367-1068
Practice Address - Fax:802-367-1069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-25
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042.0012150261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1019286Medicaid