Provider Demographics
NPI:1609385129
Name:MOULTON, LEIGH ANN
Entity Type:Individual
Prefix:
First Name:LEIGH
Middle Name:ANN
Last Name:MOULTON
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 1:5523 DIVISION AVE N
Mailing Address - Street 2:
Mailing Address - City:COMSTOCK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:49321-8214
Mailing Address - Country:US
Mailing Address - Phone:616-813-1521
Mailing Address - Fax:
Practice Address - Street 1:6290 JUPITER DRIVE SUITE C
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MI
Practice Address - Zip Code:49306
Practice Address - Country:US
Practice Address - Phone:616-813-1521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-27
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501008684225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist