Basic Information
| Provider Information | |||||||||
| NPI: | 1255769394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEICHTY | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | A. G. | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 817 | ||||||||
| Address2: | |||||||||
| City: | WEST LIBERTY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433570817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374658065 | ||||||||
| FaxNumber: | 9374650442 | ||||||||
| Practice Location | |||||||||
| Address1: | 1522 EAST US RTE 36 | ||||||||
| Address2: | SUITE A | ||||||||
| City: | URBANA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376535583 | ||||||||
| FaxNumber: | 9376534787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2013 | ||||||||
| LastUpdateDate: | 01/25/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | E100103 | OH | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YS0200X | OH 3092026 | OH | N | Behavioral Health & Social Service Providers | Counselor | School | 101YP2500X | C.1100103-CR | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.