Provider Demographics
NPI:1043772874
Name:LEICHTLE, CONNOR (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:LEICHTLE
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 CABRINI CIR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-4623
Mailing Address - Country:US
Mailing Address - Phone:262-355-6241
Mailing Address - Fax:
Practice Address - Street 1:930 EVASHEVSKI DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1186
Practice Address - Country:US
Practice Address - Phone:262-355-6241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0878332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer