Healthcare Provider Details

I. General information

NPI: 1932508702
Provider Name (Legal Business Name): LEAH YACOUB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2014
Last Update Date: 08/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21096 STRAWBERRY HILLS DR
MACOMB MI
48044-2274
US

IV. Provider business mailing address

21096 STRAWBERRY HILLS DR
MACOMB MI
48044-2274
US

V. Phone/Fax

Practice location:
  • Phone: 586-421-2205
  • Fax:
Mailing address:
  • Phone: 586-421-2205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502003135
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: