Provider Demographics
NPI:1104313709
Name:NICHOLS, LEANNE MARIE (MA, AT, ATC, PES)
Entity type:Individual
Prefix:MS
First Name:LEANNE
Middle Name:MARIE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:MA, AT, ATC, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 MANCHESTER LN APT 3211
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-2357
Mailing Address - Country:US
Mailing Address - Phone:810-874-9122
Mailing Address - Fax:
Practice Address - Street 1:4128 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-6538
Practice Address - Country:US
Practice Address - Phone:517-540-1060
Practice Address - Fax:517-540-1063
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010008382255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer