Provider Demographics
NPI:1083274138
Name:LEITCH, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:LEITCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18422 103RD AVE NE
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-3410
Mailing Address - Country:US
Mailing Address - Phone:425-949-0801
Mailing Address - Fax:
Practice Address - Street 1:18422 103RD AVE NE
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-3410
Practice Address - Country:US
Practice Address - Phone:425-949-0801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician