Provider Demographics
NPI:1386918910
Name:MACKUS, LEAH (LLMSW)
Entity type:Individual
Prefix:MRS
First Name:LEAH
Middle Name:
Last Name:MACKUS
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4163 LITTLE STAR CT SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-3021
Mailing Address - Country:US
Mailing Address - Phone:231-736-8995
Mailing Address - Fax:
Practice Address - Street 1:4525 N RAVENSWOOD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5201
Practice Address - Country:US
Practice Address - Phone:248-365-4457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-29
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL25471911041C0700X
MIL17889721041C0700X
MIP7151141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical