Provider Demographics
NPI:1578150793
Name:GANT, LESLEY
Entity Type:Individual
Prefix:MRS
First Name:LESLEY
Middle Name:
Last Name:GANT
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 1:18701 GRAND RIVER AVE # 181
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-2214
Mailing Address - Country:US
Mailing Address - Phone:313-413-7382
Mailing Address - Fax:
Practice Address - Street 1:109 W MICHIGAN AVE
Practice Address - Street 2:4TH FLOOR
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48913
Practice Address - Country:US
Practice Address - Phone:313-413-7382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-22
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801105230104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker