Provider Demographics
NPI:1497081350
Name:MITTELMAN, LESLIE JILL (MA)
Entity Type:Individual
Prefix:MISS
First Name:LESLIE
Middle Name:JILL
Last Name:MITTELMAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11630 PUERTO BLVD
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33437-4029
Mailing Address - Country:US
Mailing Address - Phone:561-699-8664
Mailing Address - Fax:
Practice Address - Street 1:11630 PUERTO BLVD
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-4029
Practice Address - Country:US
Practice Address - Phone:561-699-8664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-28
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
NJ589942174400000X
FL902399174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist