Provider Demographics
NPI:1346780665
Name:TRENTHAM, LESLIE ANNE (LLBSW, QIDP)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANNE
Last Name:TRENTHAM
Suffix:
Gender:F
Credentials:LLBSW, QIDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5281 CLYDE PARK AVE SW
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-9506
Mailing Address - Country:US
Mailing Address - Phone:616-719-4263
Mailing Address - Fax:616-719-4267
Practice Address - Street 1:5281 CLYDE PARK AVE SW
Practice Address - Street 2:SUITE 2
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-9506
Practice Address - Country:US
Practice Address - Phone:616-719-4263
Practice Address - Fax:616-719-4267
Is Sole Proprietor?:No
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802089384104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker