Provider Demographics
NPI:1285213843
Name:LEISTIKOWMD LLC
Entity Type:Organization
Organization Name:LEISTIKOWMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEISTIKOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:443-799-9384
Mailing Address - Street 1:600 WYNDHURST AVE STE 305E
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21210-2489
Mailing Address - Country:US
Mailing Address - Phone:443-799-9384
Mailing Address - Fax:
Practice Address - Street 1:600 WYNDHURST AVE STE 305E
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21210-2489
Practice Address - Country:US
Practice Address - Phone:443-459-1840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-02
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health