Healthcare Provider Details

I. General information

NPI: 1194582452
Provider Name (Legal Business Name): LESLIE HERRGUTH LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LESLIE BARNER LLMSW

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6920 SOUTH CEDAR STREET SUITE 11
LANSING MI
48911
US

IV. Provider business mailing address

13301 ALLEN ST
BATH MI
48808
US

V. Phone/Fax

Practice location:
  • Phone: 517-528-5957
  • Fax:
Mailing address:
  • Phone: 517-528-5957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851117823
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: