Healthcare Provider Details

I. General information

NPI: 1487027165
Provider Name (Legal Business Name): SCOTT LEGLEITNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2015
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 SWEET FERN WAY
TRAVERSE CITY MI
49696-8936
US

IV. Provider business mailing address

1805 SWEET FERN WAY
TRAVERSE CITY MI
49696-8936
US

V. Phone/Fax

Practice location:
  • Phone: 248-240-2313
  • Fax:
Mailing address:
  • Phone: 248-240-2313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6352000809
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number5353004501
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6451019399
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: