Provider Demographics
NPI:1225672090
Name:LEICKLY, CLARISSA N
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:N
Last Name:LEICKLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 HAYDEN LN
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3916
Mailing Address - Country:US
Mailing Address - Phone:614-329-4800
Mailing Address - Fax:
Practice Address - Street 1:75 HICKLE ST
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-4350
Practice Address - Country:US
Practice Address - Phone:724-437-9871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV004129225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist