Provider Demographics
NPI:1396173944
Name:PALMER, LESLEY
Entity type:Individual
Prefix:
First Name:LESLEY
Middle Name:
Last Name:PALMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LESLEY
Other - Middle Name:
Other - Last Name:BURNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3031 MCKINLEY STREET NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418
Mailing Address - Country:US
Mailing Address - Phone:612-207-6152
Mailing Address - Fax:
Practice Address - Street 1:5710 BAKER ROAD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343
Practice Address - Country:US
Practice Address - Phone:952-767-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-17
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN41-184-7652251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health