Provider Demographics
NPI:1922513373
Name:BLACK, LEANNE M
Entity Type:Individual
Prefix:MRS
First Name:LEANNE
Middle Name:M
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12183 W GRAND BLANC RD
Mailing Address - Street 2:
Mailing Address - City:DURAND
Mailing Address - State:MI
Mailing Address - Zip Code:48429-9308
Mailing Address - Country:US
Mailing Address - Phone:989-737-9442
Mailing Address - Fax:
Practice Address - Street 1:12183 W GRAND BLANC RD
Practice Address - Street 2:
Practice Address - City:DURAND
Practice Address - State:MI
Practice Address - Zip Code:48429-9308
Practice Address - Country:US
Practice Address - Phone:989-737-9442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-07
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI6362001412103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program