Provider Demographics
NPI:1073646774
Name:GREEN, LESLIE WEISS (PHD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:WEISS
Last Name:GREEN
Suffix:
Gender:F
Credentials:PHD
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 1563
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-1563
Mailing Address - Country:US
Mailing Address - Phone:248-593-0678
Mailing Address - Fax:248-593-9766
Practice Address - Street 1:755 W BIG BEAVER RD
Practice Address - Street 2:SUITE 414
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4900
Practice Address - Country:US
Practice Address - Phone:248-593-0678
Practice Address - Fax:248-593-9766
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005638103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI620F33143OtherBLUE CROSS PIN