Provider Demographics
NPI:1679738736
Name:LEECH, MARY ANNE (LLPC)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANNE
Last Name:LEECH
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ANNE
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1095 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49441-1976
Mailing Address - Country:US
Mailing Address - Phone:231-726-4735
Mailing Address - Fax:231-722-0789
Practice Address - Street 1:1095 3RD ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-1976
Practice Address - Country:US
Practice Address - Phone:231-726-4735
Practice Address - Fax:231-722-0789
Is Sole Proprietor?:No
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010946101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1712452Medicaid
MIOP22320Medicare PIN
MI750910903Medicare UPIN
MI1712452Medicaid
MI750910842Medicare UPIN
MI950910904Medicare UPIN
MI20366Medicare UPIN
MI750910910Medicare UPIN
MI20351Medicare UPIN
MI20386Medicare UPIN
MI750910902Medicare UPIN