Provider Demographics
NPI:1144748005
Name:HANSKNECHT, LEESA
Entity Type:Individual
Prefix:
First Name:LEESA
Middle Name:
Last Name:HANSKNECHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25645 INGLESIDE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-4844
Mailing Address - Country:US
Mailing Address - Phone:248-420-7439
Mailing Address - Fax:
Practice Address - Street 1:49881 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:WIXOM
Practice Address - State:MI
Practice Address - Zip Code:48393-3309
Practice Address - Country:US
Practice Address - Phone:248-229-4016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1418908174400000X
AZ1471967174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist