Provider Demographics
NPI:1063464436
Name:LEFLORE, FANNIE M (MS, LPC,CADC-D)
Entity Type:Individual
Prefix:MS
First Name:FANNIE
Middle Name:M
Last Name:LEFLORE
Suffix:
Gender:F
Credentials:MS, LPC,CADC-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 18376
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-0376
Mailing Address - Country:US
Mailing Address - Phone:414-438-1534
Mailing Address - Fax:
Practice Address - Street 1:6310 N PORT WASHINGTON RD
Practice Address - Street 2:OFFICE SPACE INSIDE R.E.A.C.H. CLINIC
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-4300
Practice Address - Country:US
Practice Address - Phone:414-438-1534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13220101YA0400X
WI2250-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2250-125OtherLICENSED PROF COUNSELOR
WI40920600Medicaid
WI13220OtherCADC-D