Provider Demographics
NPI:1053367581
Name:LESLIE, BENNETT (PSYD)
Entity type:Individual
Prefix:MR
First Name:BENNETT
Middle Name:
Last Name:LESLIE
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:PO BOX 6503
Mailing Address - Street 2:INTEGRATIVE MEDICINE PROGRAM
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80045-0503
Mailing Address - Country:US
Mailing Address - Phone:303-724-5000
Mailing Address - Fax:303-724-5816
Practice Address - Street 1:1635 URSULA ST
Practice Address - Street 2:SUITE # 5501
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80010-7402
Practice Address - Country:US
Practice Address - Phone:720-848-1090
Practice Address - Fax:720-848-1277
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2502103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO33739889Medicaid
COP11557Medicare UPIN
COF72677Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE ID #