Provider Demographics
NPI:1639441462
Name:LIECHTY, LAUREN KATHLEEN (RD)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:KATHLEEN
Last Name:LIECHTY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 ALBANY ST
Mailing Address - Street 2:
Mailing Address - City:BEECH GROVE
Mailing Address - State:IN
Mailing Address - Zip Code:46107-1541
Mailing Address - Country:US
Mailing Address - Phone:317-528-3955
Mailing Address - Fax:
Practice Address - Street 1:1600 ALBANY ST
Practice Address - Street 2:
Practice Address - City:BEECH GROVE
Practice Address - State:IN
Practice Address - Zip Code:46107-1541
Practice Address - Country:US
Practice Address - Phone:317-528-3955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1023574133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered