Provider Demographics
NPI:1376159855
Name:BANTOLINA, LEZLEY (MS, LPC)
Entity Type:Individual
Prefix:
First Name:LEZLEY
Middle Name:
Last Name:BANTOLINA
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 MUNICIPAL DR STE D
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010-1043
Mailing Address - Country:US
Mailing Address - Phone:636-333-2641
Mailing Address - Fax:573-803-1405
Practice Address - Street 1:16 MUNICIPAL DR STE D
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-1043
Practice Address - Country:US
Practice Address - Phone:636-333-2641
Practice Address - Fax:573-803-1405
Is Sole Proprietor?:No
Enumeration Date:2020-09-19
Last Update Date:2020-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional