Provider Demographics
NPI:1003875758
Name:LEICHTBERG, JUDITH (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:
Last Name:LEICHTBERG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032
Mailing Address - Country:US
Mailing Address - Phone:860-677-2550
Mailing Address - Fax:860-677-4975
Practice Address - Street 1:1301 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032
Practice Address - Country:US
Practice Address - Phone:860-677-2550
Practice Address - Fax:860-677-4975
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0034891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT211793OtherMANAGED HEALTH NET
CT140003489CT04OtherANTHEM BC