Provider Demographics
NPI:1407003130
Name:LIECHTY, PAUL MICAH (DC)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:MICAH
Last Name:LIECHTY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1823 BOURBON RD
Mailing Address - Street 2:
Mailing Address - City:CROSS PLAINS
Mailing Address - State:WI
Mailing Address - Zip Code:53528-9436
Mailing Address - Country:US
Mailing Address - Phone:608-798-3300
Mailing Address - Fax:
Practice Address - Street 1:1823 BOURBON RD
Practice Address - Street 2:
Practice Address - City:CROSS PLAINS
Practice Address - State:WI
Practice Address - Zip Code:53528-9436
Practice Address - Country:US
Practice Address - Phone:608-798-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-25
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI549212111N00000X
TX10956111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor