Provider Demographics
NPI:1871711432
Name:LEICHTY, LAURA FORGENG (OTR,L)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:FORGENG
Last Name:LEICHTY
Suffix:
Gender:F
Credentials:OTR,L
Other - Prefix:MISS
Other - First Name:LAURA
Other - Middle Name:ANN
Other - Last Name:FORGENG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR,L
Mailing Address - Street 1:213 ARBORLEA AVE
Mailing Address - Street 2:
Mailing Address - City:YARDLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19067-7409
Mailing Address - Country:US
Mailing Address - Phone:757-812-8862
Mailing Address - Fax:
Practice Address - Street 1:213 ARBORLEA AVE
Practice Address - Street 2:
Practice Address - City:YARDLEY
Practice Address - State:PA
Practice Address - Zip Code:19067-7409
Practice Address - Country:US
Practice Address - Phone:757-812-8862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC010041225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101580641 0001Medicaid