Provider Demographics
NPI:1679503700
Name:LEON, IRVING GLENN (PHD)
Entity Type:Individual
Prefix:DR
First Name:IRVING
Middle Name:GLENN
Last Name:LEON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3117 OVERRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-4152
Mailing Address - Country:US
Mailing Address - Phone:734-971-5768
Mailing Address - Fax:
Practice Address - Street 1:2311 E STADIUM BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-4833
Practice Address - Country:US
Practice Address - Phone:734-662-2055
Practice Address - Fax:734-662-6268
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002943103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOH14690OtherBCBS MICHIGAN