Provider Demographics
NPI:1730654286
Name:LIECHTY, LARRY ROBERT
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:ROBERT
Last Name:LIECHTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 SW HOLDEN ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98126-3505
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15035 8TH AVE S
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98148-1112
Practice Address - Country:US
Practice Address - Phone:206-241-3119
Practice Address - Fax:206-241-0184
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-11
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator