Provider Demographics
NPI:1902348550
Name:BURTON, LESLIE A (PHD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:BURTON
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 1:7 RIVER RD
Mailing Address - Street 2:UNIT 305
Mailing Address - City:COS COB
Mailing Address - State:CT
Mailing Address - Zip Code:06807-2723
Mailing Address - Country:US
Mailing Address - Phone:203-637-2930
Mailing Address - Fax:
Practice Address - Street 1:GAYLORD FARM RD
Practice Address - Street 2:GAYLORD HOSPITAL
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492
Practice Address - Country:US
Practice Address - Phone:203-284-2800
Practice Address - Fax:203-294-3294
Is Sole Proprietor?:No
Enumeration Date:2016-11-14
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1456103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist