Provider Demographics
NPI:1730397183
Name:FRY, LEIV A (LMSW)
Entity type:Individual
Prefix:
First Name:LEIV
Middle Name:A
Last Name:FRY
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 1:17134 LOUISE DR
Mailing Address - Street 2:
Mailing Address - City:DAVISBURG
Mailing Address - State:MI
Mailing Address - Zip Code:48350-3930
Mailing Address - Country:US
Mailing Address - Phone:810-618-3079
Mailing Address - Fax:810-232-2782
Practice Address - Street 1:1110 ELDON BAKER DR
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-1923
Practice Address - Country:US
Practice Address - Phone:810-618-3079
Practice Address - Fax:810-232-2782
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010932441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical