Provider Demographics
NPI:1528248192
Name:ETTS, LEA S (PC)
Entity type:Individual
Prefix:
First Name:LEA
Middle Name:S
Last Name:ETTS
Suffix:
Gender:F
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14930 LAPLAISANCE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-3880
Mailing Address - Country:US
Mailing Address - Phone:734-241-4851
Mailing Address - Fax:734-241-6552
Practice Address - Street 1:14930 LAPLAISANCE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-3880
Practice Address - Country:US
Practice Address - Phone:734-241-4851
Practice Address - Fax:734-241-6552
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-12
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401009249101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health