Provider Demographics
NPI:1639426505
Name:RAYMO, LEA ANN (PHD, LLP)
Entity Type:Individual
Prefix:DR
First Name:LEA
Middle Name:ANN
Last Name:RAYMO
Suffix:
Gender:F
Credentials:PHD, LLP
Other - Prefix:
Other - First Name:LEA
Other - Middle Name:ANN
Other - Last Name:IMASA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD, LLP
Mailing Address - Street 1:26901 BEAUMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30503 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-1594
Practice Address - Country:US
Practice Address - Phone:248-691-4744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015145103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical