Healthcare Provider Details

I. General information

NPI: 1457953838
Provider Name (Legal Business Name): LEIGH ELLIS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2020
Last Update Date: 05/09/2023
Certification Date: 05/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MONROE AVE NW
GRAND RAPIDS MI
49503-1455
US

IV. Provider business mailing address

1525 TREMONT BLVD NW
GRAND RAPIDS MI
49504-4864
US

V. Phone/Fax

Practice location:
  • Phone: 616-259-7207
  • Fax:
Mailing address:
  • Phone: 616-648-0441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401018747
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: