Healthcare Provider Details

I. General information

NPI: 1902981103
Provider Name (Legal Business Name): LESLIE GREENE MACAULEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4970 NORTHWIND DR
EAST LANSING MI
48823-5080
US

IV. Provider business mailing address

611 COURT ST PO BOX 428
WEST BRANCH MI
48661-9390
US

V. Phone/Fax

Practice location:
  • Phone: 989-345-1000
  • Fax: 989-345-5803
Mailing address:
  • Phone: 989-345-1000
  • Fax: 989-345-5803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number4301062299
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: