Provider Demographics
NPI:1235522707
Name:LEESE, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:LEESE
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 1:17383 DEERING ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-3703
Mailing Address - Country:US
Mailing Address - Phone:734-828-4043
Mailing Address - Fax:
Practice Address - Street 1:120 STEVENS ST SW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-1526
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-09
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
MI103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other