Provider Demographics
NPI:1417183807
Name:LICHWICK, LEEANNE (COTA)
Entity Type:Individual
Prefix:MISS
First Name:LEEANNE
Middle Name:
Last Name:LICHWICK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 YANKEE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WURTSBORO
Mailing Address - State:NY
Mailing Address - Zip Code:12790-2060
Mailing Address - Country:US
Mailing Address - Phone:845-866-5070
Mailing Address - Fax:845-644-4016
Practice Address - Street 1:101 KLOTHE DR
Practice Address - Street 2:
Practice Address - City:GRAHAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12740-5805
Practice Address - Country:US
Practice Address - Phone:845-985-7080
Practice Address - Fax:845-985-7070
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-31
Last Update Date:2009-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006083-1252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency