Provider Demographics
NPI:1952755191
Name:BARDESSONO, LESLIE CAROL (DO)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:CAROL
Last Name:BARDESSONO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2242 S SWEETBRIAR CIR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-4600
Mailing Address - Country:US
Mailing Address - Phone:707-332-9048
Mailing Address - Fax:
Practice Address - Street 1:31764 CASINO DR # 300
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-2312
Practice Address - Country:US
Practice Address - Phone:951-471-4645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-13
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT032.01340752084P0800X
ARE-123712084P0800X
IN0200619A2084P0800X
WY13060A2084P0800X
CA20A208482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR309200000XMedicaid