Basic Information
| Provider Information | |||||||||
| NPI: | 1316995897 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 LEPNAPE TRL | ||||||||
| Address2: | |||||||||
| City: | MONTCLAIR | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070431628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9732330836 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | ALBANY POST ROAD | ||||||||
| Address2: | VA HUDSON VALLEY HEALTH CARE SYSTEM | ||||||||
| City: | MONTROSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9147374400 | ||||||||
| FaxNumber: | 9147884285 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 12/12/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | NY7972 | NY | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.