Provider Demographics
NPI:1194056457
Name:LEONARD, TIMOTHY GERARD (LMSW)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:GERARD
Last Name:LEONARD
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1148 ORCHARD AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-3547
Mailing Address - Country:US
Mailing Address - Phone:616-855-5151
Mailing Address - Fax:
Practice Address - Street 1:680 3 MILE RD NW STE 150
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-8218
Practice Address - Country:US
Practice Address - Phone:616-647-3460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-26
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801082003101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor