Provider Demographics
NPI:1518307479
Name:HEIDRICH, LESLEY M (LAC, CMLDT, RT(T))
Entity Type:Individual
Prefix:MISS
First Name:LESLEY
Middle Name:M
Last Name:HEIDRICH
Suffix:
Gender:F
Credentials:LAC, CMLDT, RT(T)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 W IRVING PARK RD
Mailing Address - Street 2:#1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-3924
Mailing Address - Country:US
Mailing Address - Phone:773-295-7319
Mailing Address - Fax:
Practice Address - Street 1:6374 N LINCOLN AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-1275
Practice Address - Country:US
Practice Address - Phone:773-295-7319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-25
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198001097171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist