Provider Demographics
NPI:1902634512
Name:STOLLER, LESLEY WHITMAN
Entity type:Individual
Prefix:
First Name:LESLEY
Middle Name:WHITMAN
Last Name:STOLLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 VALLEY VIEW RD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-3917
Mailing Address - Country:US
Mailing Address - Phone:516-376-0872
Mailing Address - Fax:
Practice Address - Street 1:25 VALLEY VIEW RD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-3917
Practice Address - Country:US
Practice Address - Phone:516-376-0872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-24
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001202-01102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst