Provider Demographics
NPI:1124424874
Name:LEACH, DEIANIRA C (LPC, LLP)
Entity type:Individual
Prefix:
First Name:DEIANIRA
Middle Name:C
Last Name:LEACH
Suffix:
Gender:F
Credentials:LPC, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 MILLSTONE DR
Mailing Address - Street 2:STE D407
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-2954
Mailing Address - Country:US
Mailing Address - Phone:734-604-0247
Mailing Address - Fax:
Practice Address - Street 1:30701 WOODWARD AVE
Practice Address - Street 2:STE 200
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-0987
Practice Address - Country:US
Practice Address - Phone:248-288-9333
Practice Address - Fax:248-288-1362
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-07
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016226103T00000X
MI6401008170101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103T00000XBehavioral Health & Social Service ProvidersPsychologist