Provider Demographics
NPI:1376186841
Name:LIECHTY, TREVOR MATTHEW
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:MATTHEW
Last Name:LIECHTY
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 1:8966 SPRING VIOLET PL
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-7506
Mailing Address - Country:US
Mailing Address - Phone:317-797-1825
Mailing Address - Fax:
Practice Address - Street 1:8966 SPRING VIOLET PL
Practice Address - Street 2:
Practice Address - City:ZIONSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46077-7506
Practice Address - Country:US
Practice Address - Phone:317-797-1825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer