Provider Demographics
NPI:1528528478
Name:LECLAIRE, DENISE R (MA, LLP)
Entity type:Individual
Prefix:MS
First Name:DENISE
Middle Name:R
Last Name:LECLAIRE
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 SHELDON RD
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-1860
Mailing Address - Country:US
Mailing Address - Phone:616-801-3792
Mailing Address - Fax:
Practice Address - Street 1:234 1/2 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-1375
Practice Address - Country:US
Practice Address - Phone:616-607-4476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008788103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICV0012326Medicaid