Provider Demographics
NPI:1679766240
Name:LECLAIR, CRISTINA I (PSY D LP)
Entity Type:Individual
Prefix:MRS
First Name:CRISTINA
Middle Name:I
Last Name:LECLAIR
Suffix:
Gender:F
Credentials:PSY D LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 N LEROY ST STE A
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-2789
Mailing Address - Country:US
Mailing Address - Phone:819-373-5591
Mailing Address - Fax:
Practice Address - Street 1:1122 N LEROY ST STE A
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2789
Practice Address - Country:US
Practice Address - Phone:810-373-5591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-27
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013013103T00000X
MI6301018287103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist