Provider Demographics
NPI:1568822963
Name:LEARY, MANISHA
Entity type:Individual
Prefix:
First Name:MANISHA
Middle Name:
Last Name:LEARY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 MACK AVE.
Mailing Address - Street 2:CREDENTIALING DEPT.
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-1138
Mailing Address - Country:US
Mailing Address - Phone:313-448-9006
Mailing Address - Fax:313-993-3421
Practice Address - Street 1:3901 CHRYSLER SERVICE DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2167
Practice Address - Country:US
Practice Address - Phone:313-993-3434
Practice Address - Fax:313-993-3421
Is Sole Proprietor?:No
Enumeration Date:2016-02-26
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010920471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical