Provider Demographics
NPI:1316995897
Name:GREEN, LESLIE WAYNE (PHD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:WAYNE
Last Name:GREEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 LEPNAPE TRL
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07043-1628
Mailing Address - Country:US
Mailing Address - Phone:973-233-0836
Mailing Address - Fax:
Practice Address - Street 1:ALBANY POST ROAD
Practice Address - Street 2:VA HUDSON VALLEY HEALTH CARE SYSTEM
Practice Address - City:MONTROSE
Practice Address - State:NY
Practice Address - Zip Code:10548
Practice Address - Country:US
Practice Address - Phone:914-737-4400
Practice Address - Fax:914-788-4285
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY7972103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist