Provider Demographics
NPI:1982307716
Name:LEESTMA, ERIN AMELIA (MD)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:AMELIA
Last Name:LEESTMA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 MELBOURNE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2507
Mailing Address - Country:US
Mailing Address - Phone:616-499-5940
Mailing Address - Fax:
Practice Address - Street 1:LOYOLA UNIVERSITY MEDICAL CENTER
Practice Address - Street 2:BUILDING 105, SUITE 1940
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-216-6200
Practice Address - Fax:708-216-6840
Is Sole Proprietor?:No
Enumeration Date:2023-03-22
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1250827472084P0800X
IL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry