Basic Information
| Provider Information | |||||||||
| NPI: | 1659341956 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WITHIAM LEITCH | ||||||||
| FirstName: | SHERRY | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 TREMONT ST | ||||||||
| Address2: | |||||||||
| City: | N TONAWANDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141206135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166891901 | ||||||||
| FaxNumber: | 7166892238 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 TREMONT ST | ||||||||
| Address2: | |||||||||
| City: | N TONAWANDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141206135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166891901 | ||||||||
| FaxNumber: | 7166892238 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 202583-1 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 01686915 | 05 | NY | MEDICAID |