Provider Demographics
NPI:1043013428
Name:GLENN, DEWAND LESHAWN
Entity type:Individual
Prefix:MR
First Name:DEWAND
Middle Name:LESHAWN
Last Name:GLENN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26100 HOFFMEYER ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4915
Mailing Address - Country:US
Mailing Address - Phone:313-926-9442
Mailing Address - Fax:
Practice Address - Street 1:12103 ROSEMARY ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-1366
Practice Address - Country:US
Practice Address - Phone:313-614-7567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIG450139511724374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide