=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043013428
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. DEWAND LESHAWN GLENN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2025
-----------------------------------------------------
Last Update Date | 03/31/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12103 ROSEMARY ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48213-1366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-614-7567
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26100 HOFFMEYER ST
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48066-4915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-926-9442
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number | G450139511724
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------