Provider Demographics
NPI:1699009571
Name:LEICHTLE, AMBER (LMSW LADAC)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:LEICHTLE
Suffix:
Gender:F
Credentials:LMSW LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 INDUSTRIAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-3453
Mailing Address - Country:US
Mailing Address - Phone:505-753-3143
Mailing Address - Fax:
Practice Address - Street 1:1122 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-3453
Practice Address - Country:US
Practice Address - Phone:505-753-3143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-25
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0071001101YA0400X
NMM-04710101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)