Provider Demographics
NPI:1700823390
Name:LEICHTMAN, MARTIN (PH D)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:LEICHTMAN
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3133 BELLWETHER DR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60503-3116
Mailing Address - Country:US
Mailing Address - Phone:913-961-5226
Mailing Address - Fax:
Practice Address - Street 1:2272 95TH ST STE 305
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-8944
Practice Address - Country:US
Practice Address - Phone:630-753-9800
Practice Address - Fax:913-345-1464
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS296103TC0700X
IL071.011161103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS000B697Medicare ID - Type UnspecifiedPSYCHOLOGIST