Provider Demographics
NPI:1396280699
Name:MADILL, LESLIE (LMSW)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:MADILL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 N WASHINGTON ST
Mailing Address - Street 2:SUITE 13
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-2662
Mailing Address - Country:US
Mailing Address - Phone:734-489-4709
Mailing Address - Fax:
Practice Address - Street 1:32 N WASHINGTON ST
Practice Address - Street 2:SUITE 13
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-2662
Practice Address - Country:US
Practice Address - Phone:734-489-4709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-23
Last Update Date:2016-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010785341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical