Provider Demographics
NPI:1063915304
Name:SMITH, LEANN NICOLE (LPC)
Entity type:Individual
Prefix:MRS
First Name:LEANN
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:LEANN
Other - Middle Name:NICOLE
Other - Last Name:BASTIEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:4241 KALAMAZOO DRIVE
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49316-9606
Mailing Address - Country:US
Mailing Address - Phone:616-730-1302
Mailing Address - Fax:
Practice Address - Street 1:4241 KALAMAZOO DRIVE
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-9606
Practice Address - Country:US
Practice Address - Phone:616-730-1302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016474101Y00000X
MI6401224764101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor