Provider Demographics
NPI:1740891498
Name:DANTZLER, LEATHE (MS)
Entity type:Individual
Prefix:MS
First Name:LEATHE
Middle Name:
Last Name:DANTZLER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 E FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-1098
Mailing Address - Country:US
Mailing Address - Phone:313-833-4291
Mailing Address - Fax:313-833-5730
Practice Address - Street 1:1025 E FOREST AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-1098
Practice Address - Country:US
Practice Address - Phone:313-833-4291
Practice Address - Fax:313-833-5730
Is Sole Proprietor?:No
Enumeration Date:2020-08-14
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009899103T00000X
MI6361003896103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist