Basic Information
| Provider Information | |||||||||
| NPI: | 1124424874 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEACH | ||||||||
| FirstName: | DEIANIRA | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | LPC, LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 54 MILLSTONE DR | ||||||||
| Address2: | STE D407 | ||||||||
| City: | WATERFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483282954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346040247 | ||||||||
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| Practice Location | |||||||||
| Address1: | 30701 WOODWARD AVE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480730987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482889333 | ||||||||
| FaxNumber: | 2482881362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2014 | ||||||||
| LastUpdateDate: | 04/07/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6301016226 | MI | N | Behavioral Health & Social Service Providers | Psychologist | 101YP2500X | 6401008170 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.