Provider Demographics
NPI:1912238411
Name:KOBURG, LEIGH ANNE (LMSW)
Entity Type:Individual
Prefix:
First Name:LEIGH
Middle Name:ANNE
Last Name:KOBURG
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48080 BURTON DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48317-2406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1450 S LAPEER RD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MI
Practice Address - Zip Code:48371-6108
Practice Address - Country:US
Practice Address - Phone:248-969-9932
Practice Address - Fax:248-969-0840
Is Sole Proprietor?:No
Enumeration Date:2010-01-22
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010859021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical