Healthcare Provider Details

I. General information

NPI: 1932588654
Provider Name (Legal Business Name): LESLIE COLLINS LBSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2015
Last Update Date: 05/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35425 W MICHIGAN AVE
WAYNE MI
48184-9800
US

IV. Provider business mailing address

28102 MAPLEWOOD ST
GARDEN CITY MI
48135-2215
US

V. Phone/Fax

Practice location:
  • Phone: 734-467-7699
  • Fax: 734-467-7646
Mailing address:
  • Phone: 735-467-7600
  • Fax: 734-467-7646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802077403
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: