Healthcare Provider Details

I. General information

NPI: 1558408617
Provider Name (Legal Business Name): LESLIE T. HEFNER LESLIE HEFNER PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 LITTLE LAKE DR #33
ANN ARBOR MI
48103-6207
US

IV. Provider business mailing address

424 LITTLE LAKE DR #33
ANN ARBOR MI
48103-6207
US

V. Phone/Fax

Practice location:
  • Phone: 734-663-0668
  • Fax: 734-662-3958
Mailing address:
  • Phone: 734-663-0668
  • Fax: 734-662-3958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301000430
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: