Basic Information
| Provider Information | |||||||||
| NPI: | 1679807671 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEICHT | ||||||||
| FirstName: | ANNIE | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 771 W BLAINE ST STE D | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925073940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514415542 | ||||||||
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| Practice Location | |||||||||
| Address1: | 623 N MAIN ST | ||||||||
| Address2: | SUITE D-11 | ||||||||
| City: | CORONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928801407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517372962 | ||||||||
| FaxNumber: | 9517372783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2009 | ||||||||
| LastUpdateDate: | 07/23/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.