Provider Demographics
NPI:1881936383
Name:LEICHENTRITT, STACY MARIE (LMT)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:MARIE
Last Name:LEICHENTRITT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 WILD CHERRY DR
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:NC
Mailing Address - Zip Code:28721-7531
Mailing Address - Country:US
Mailing Address - Phone:719-500-9772
Mailing Address - Fax:
Practice Address - Street 1:42 WILD CHERRY DR
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:NC
Practice Address - Zip Code:28721-7531
Practice Address - Country:US
Practice Address - Phone:719-500-9772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-22
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT0012498174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No174400000XOther Service ProvidersSpecialist