Provider Demographics
NPI:1376293084
Name:ADDERTY, LEELYANI
Entity Type:Individual
Prefix:
First Name:LEELYANI
Middle Name:
Last Name:ADDERTY
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 1:105 W ANTHONY ST
Mailing Address - Street 2:
Mailing Address - City:LAKE LEELANAU
Mailing Address - State:MI
Mailing Address - Zip Code:49653-9696
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:945 BARLOW ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-4250
Practice Address - Country:US
Practice Address - Phone:231-268-0070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician