Provider Demographics
NPI:1902981103
Name:MACAULEY, LESLIE GREENE (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:GREENE
Last Name:MACAULEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 COURT ST
Mailing Address - Street 2:PO BOX 428
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-9390
Mailing Address - Country:US
Mailing Address - Phone:989-345-1000
Mailing Address - Fax:989-345-5803
Practice Address - Street 1:4970 NORTHWIND DR
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5080
Practice Address - Country:US
Practice Address - Phone:989-345-1000
Practice Address - Fax:989-345-5803
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010622992084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4455930Medicaid
G37550Medicare UPIN
0P15900Medicare ID - Type Unspecified