Provider Demographics
NPI:1174266373
Name:LESLIE W. GREEN, PHD, P.C.
Entity Type:Organization
Organization Name:LESLIE W. GREEN, PHD, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:W
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:248-765-8366
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:248-765-8366
Mailing Address - Fax:
Practice Address - Street 1:1740 W BIG BEAVER RD STE 206
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-3507
Practice Address - Country:US
Practice Address - Phone:248-593-0678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-15
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)