Provider Demographics
NPI:1073197943
Name:MCAULIFFE, LEANN (LLP)
Entity Type:Individual
Prefix:
First Name:LEANN
Middle Name:
Last Name:MCAULIFFE
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7125 HEADLEY ST. SE #733
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:640 3 MILE RD NW STE G
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-8209
Practice Address - Country:US
Practice Address - Phone:586-204-6417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-07
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361004856103T00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty