Healthcare Provider Details

I. General information

NPI: 1396303418
Provider Name (Legal Business Name): MALLORY LEJMAN CGC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MALLORY WAGNER CGC

II. Dates (important events)

Enumeration Date: 06/04/2019
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E MEDICAL CENTER DR
ANN ARBOR MI
48109-5000
US

IV. Provider business mailing address

3621 S STATE ST
ANN ARBOR MI
48108-1633
US

V. Phone/Fax

Practice location:
  • Phone: 734-936-4000
  • Fax:
Mailing address:
  • Phone: 734-647-5299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number7201000049
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: