Provider Demographics
NPI:1336231042
Name:NETLAND, LESLIE A (PSYD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:NETLAND
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1686 FLICKINGER HILL RD
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-9022
Mailing Address - Country:US
Mailing Address - Phone:330-262-1237
Mailing Address - Fax:
Practice Address - Street 1:210 E MILLTOWN RD
Practice Address - Street 2:SUITE B
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-1246
Practice Address - Country:US
Practice Address - Phone:330-345-3418
Practice Address - Fax:330-345-3420
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5286103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCP20726Medicare PIN