Provider Demographics
NPI:1336552959
Name:GELLIS, LESLIE (PHD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:GELLIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:LES
Other - Middle Name:
Other - Last Name:GELLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:804 UNIVERSITY AVE
Mailing Address - Street 2:201
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1721
Mailing Address - Country:US
Mailing Address - Phone:315-443-3595
Mailing Address - Fax:
Practice Address - Street 1:804 UNIVERSITY AVE
Practice Address - Street 2:201
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1721
Practice Address - Country:US
Practice Address - Phone:315-443-3595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018822-1103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral