Provider Demographics
NPI:1851677736
Name:LEONG, LAURA (MA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:LEONG
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2761 E JEFFERSON
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207
Mailing Address - Country:US
Mailing Address - Phone:313-993-3964
Mailing Address - Fax:313-993-1372
Practice Address - Street 1:2761 E JEFFERSON
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207
Practice Address - Country:US
Practice Address - Phone:313-993-3964
Practice Address - Fax:313-993-1372
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program