Healthcare Provider Details

I. General information

NPI: 1558281295
Provider Name (Legal Business Name): GYNAH LECIA ROUSE LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GYNAH LECIA ROUSE RN

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42590 STEPNITZ DR
CLINTON TWP MI
48036-3161
US

IV. Provider business mailing address

23636 CARLINGTON ST
CLINTON TWP MI
48036-3108
US

V. Phone/Fax

Practice location:
  • Phone: 586-954-1838
  • Fax:
Mailing address:
  • Phone: 586-954-1838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number4703112980
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: