Healthcare Provider Details

I. General information

NPI: 1982070181
Provider Name (Legal Business Name): MISTY JEAN DELEON MA, TLLP, DP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISTY JEAN GIBSON

II. Dates (important events)

Enumeration Date: 08/11/2015
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 STODDARD RD
RICHMOND MI
48062-2505
US

IV. Provider business mailing address

400 STODDARD RD
RICHMOND MI
48062-2505
US

V. Phone/Fax

Practice location:
  • Phone: 810-392-2167
  • Fax:
Mailing address:
  • Phone: 810-392-2167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: