Provider Demographics
NPI:1568166759
Name:EVANOFF, LEEANNE
Entity Type:Individual
Prefix:
First Name:LEEANNE
Middle Name:
Last Name:EVANOFF
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 1:5488 MORGAN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-5700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5488 MORGAN LAKE DR
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48348-5700
Practice Address - Country:US
Practice Address - Phone:248-252-1459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool