Provider Demographics
NPI:1558047373
Name:SHELLEY, LEILA NICOLE
Entity Type:Individual
Prefix:
First Name:LEILA
Middle Name:NICOLE
Last Name:SHELLEY
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 1:6160 VILLAGE PARK DR APT 104
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-2140
Mailing Address - Country:US
Mailing Address - Phone:704-648-7058
Mailing Address - Fax:
Practice Address - Street 1:35425 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-9800
Practice Address - Country:US
Practice Address - Phone:734-756-2597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator