Healthcare Provider Details

I. General information

NPI: 1801552336
Provider Name (Legal Business Name): CURTIS GRADIE LEIPOLD PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2021
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6549 TOWN CENTER DR
CLARKSTON MI
48346-4824
US

IV. Provider business mailing address

702 S GAINSBOROUGH AVE
ROYAL OAK MI
48067-2985
US

V. Phone/Fax

Practice location:
  • Phone: 248-620-6400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704257453
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: