Provider Demographics
NPI:1720030018
Name:BISSELL, LESLIE (PHD, HSPP)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:BISSELL
Suffix:
Gender:F
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4323
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47804-0323
Mailing Address - Country:US
Mailing Address - Phone:812-231-8323
Mailing Address - Fax:812-231-8400
Practice Address - Street 1:88 WABASH CT
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-3439
Practice Address - Country:US
Practice Address - Phone:812-231-8316
Practice Address - Fax:812-232-7423
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041962103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN608960TTMedicare ID - Type Unspecified