Provider Demographics
NPI:1578687257
Name:WOLFE, LEIA (RSST, CAC1)
Entity Type:Individual
Prefix:MS
First Name:LEIA
Middle Name:
Last Name:WOLFE
Suffix:
Gender:F
Credentials:RSST, CAC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16997 ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-5401
Mailing Address - Country:US
Mailing Address - Phone:248-543-1090
Mailing Address - Fax:248-543-0017
Practice Address - Street 1:2710 12 MILE RD
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-1630
Practice Address - Country:US
Practice Address - Phone:248-543-1090
Practice Address - Fax:248-543-0017
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801075665101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)