Provider Demographics
NPI:1104955061
Name:WEIDENMAN, LESLIE (PHD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:
Last Name:WEIDENMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 STENTON AVE
Mailing Address - Street 2:APT 312
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-2741
Mailing Address - Country:US
Mailing Address - Phone:401-274-6310
Mailing Address - Fax:401-421-3280
Practice Address - Street 1:86 MOUNT HOPE AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-1648
Practice Address - Country:US
Practice Address - Phone:401-274-6310
Practice Address - Fax:401-421-3280
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS00269103T00000X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
RILW23739Medicaid
RI30890-2OtherBLUE CROSS
RI412380OtherBLUE CHIP