Provider Demographics
NPI:1265678338
Name:ROBERTS, LESLIE BARBARA
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:BARBARA
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:BARBARA
Other - Last Name:BOLT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:890 WASHINGTON AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7731
Mailing Address - Country:US
Mailing Address - Phone:616-460-0174
Mailing Address - Fax:
Practice Address - Street 1:890 WASHINGTON AVE STE 150
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-7731
Practice Address - Country:US
Practice Address - Phone:616-460-0174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-19
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012799103TC1900X
MI6351004229103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling