Provider Demographics
NPI:1336670702
Name:LIECHTY, REVATHI LAKKAKULA (DPT)
Entity Type:Individual
Prefix:
First Name:REVATHI
Middle Name:LAKKAKULA
Last Name:LIECHTY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2826 RANDOLPH RD FL 2
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1359
Mailing Address - Country:US
Mailing Address - Phone:704-366-5521
Mailing Address - Fax:
Practice Address - Street 1:2826 RANDOLPH RD FL 2
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1359
Practice Address - Country:US
Practice Address - Phone:704-366-5521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP18103225100000X
OK5275225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist