Provider Demographics
NPI:1134152770
Name:WEISS, LESLIE BLOCH (PHD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:BLOCH
Last Name:WEISS
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 1:315 WHITNEY AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-3715
Mailing Address - Country:US
Mailing Address - Phone:203-865-6156
Mailing Address - Fax:203-777-2257
Practice Address - Street 1:315 WHITNEY AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-3715
Practice Address - Country:US
Practice Address - Phone:203-865-6156
Practice Address - Fax:203-777-2257
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT629103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT6896475OtherVALUE OPTIONS
CTMHNOther173197
CT060000629CT01OtherANTHEM
CT800000944Medicare ID - Type UnspecifiedPROVIDER ID