MEDICARE: MR. JUAN LEAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	6301015283	MI

General Provider Information

NPI Number	:	1861874976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JUAN LEAL

Provider Business Mailing Address
First Line	:	38913 COUNTRY CIR
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48331-1029
Country	:	US
Telephone Number	:	248-592-5248
Fax Number	:

Provider Business Practice Location Address
First Line	:	1777 AXTELL DR
Second Line	:	STE 100
City	:	TROY
State	:	MI
Zip	:	48084-4404
Country	:	US
Telephone Number	:	248-613-5377
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2015
Last Update Date	:	06/25/2015

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