Basic Information
| Provider Information | |||||||||
| NPI: | 1467530618 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEICHT | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8483 SILVERWIND DR | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381251730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9896571370 | ||||||||
| FaxNumber: | 9018210341 | ||||||||
| Practice Location | |||||||||
| Address1: | 1282 UNION AVE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381043414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9896571370 | ||||||||
| FaxNumber: | 8186712225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 07/28/2016 | ||||||||
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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 | 174400000X | LL069193 | MI | N | Other Service Providers | Specialist | 174400000X | 48942 | TN | N | Other Service Providers | Specialist | 208100000X | 48942 | TN | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 1529398 | 05 | TN | MEDICAID | LL069193 | 01 | MI | STATE LIS # | OTHER | 4657739 | 05 | MI | MEDICAID | 4337224 | 01 | TN | BCBS OF TN | OTHER | 5921502 | 05 | NC | MEDICAID |