Provider Demographics
NPI:1760080543
Name:LE, JOHN PHONG (MA, SCL, LLPC, NCC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PHONG
Last Name:LE
Suffix:
Gender:M
Credentials:MA, SCL, LLPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44548 BAYVIEW AVE APT 26112
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-7358
Mailing Address - Country:US
Mailing Address - Phone:586-946-1358
Mailing Address - Fax:
Practice Address - Street 1:3138 HILTON RD
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-1039
Practice Address - Country:US
Practice Address - Phone:248-232-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017606101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health