Provider Demographics
NPI:1114931615
Name:LEACH, CAROL ANN LOVE (MA LLP)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN LOVE
Last Name:LEACH
Suffix:
Gender:F
Credentials:MA LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 HICKORY LN
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-2570
Mailing Address - Country:US
Mailing Address - Phone:248-830-6357
Mailing Address - Fax:248-626-8836
Practice Address - Street 1:5665 W MAPLE RD STE A
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3741
Practice Address - Country:US
Practice Address - Phone:248-830-6357
Practice Address - Fax:248-626-8836
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008640103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC11712865OtherCAQH