Healthcare Provider Details

I. General information

NPI: 1932929700
Provider Name (Legal Business Name): LEIGHA DEEANNA EDMONSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2024
Last Update Date: 10/15/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 W MAIN ST
OWOSSO MI
48867
US

IV. Provider business mailing address

2521 N ELMS RD
FLUSHING MI
48433-9423
US

V. Phone/Fax

Practice location:
  • Phone: 810-373-5276
  • Fax:
Mailing address:
  • Phone: 866-498-3909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: