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General NPI Number Information
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NPI Number | 1366994410
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Entity Type | Organization
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Legal Business Name | INTENTIONAL WELLBEING LLC
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Dates
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Enumeration Date | 10/25/2016
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Last Update Date | 09/25/2020
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Provider Practice Location Address
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Address Line | 1122 N. LEROY RD SUITE A
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City | FENTON
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State | MI
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Zip | 48430
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Country | US
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Telephone | 810-373-5591
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Fax |
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Provider Business Mailing Address
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Address Line | 1122 N. LEROY RD SUITE A
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City | FENTON
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State | MI
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Zip | 48430
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Country | US
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Telephone | 810-373-5591
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. CRISTINA LECLAIR
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Credential | PSYD LP
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Telephone | 810-373-5591
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 6301015165
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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