Provider Demographics
NPI:1043756257
Name:LEISGANG, NICOLE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:LEISGANG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4217 SMITH RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-4107
Mailing Address - Country:US
Mailing Address - Phone:513-871-7285
Mailing Address - Fax:513-871-7281
Practice Address - Street 1:4217 SMITH RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45212-4107
Practice Address - Country:US
Practice Address - Phone:513-871-7285
Practice Address - Fax:513-871-7281
Is Sole Proprietor?:No
Enumeration Date:2017-01-11
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6165103T00000X
IN20042365A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist