Provider Demographics
NPI:1861690653
Name:LEITSCHUH, GLORIA A JR (PHD)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:A
Last Name:LEITSCHUH
Suffix:JR
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9462 N C R 2000 E
Mailing Address - Street 2:
Mailing Address - City:ASHMORE
Mailing Address - State:IL
Mailing Address - Zip Code:61912
Mailing Address - Country:US
Mailing Address - Phone:217-345-3206
Mailing Address - Fax:
Practice Address - Street 1:9462 N C R 2000 E
Practice Address - Street 2:
Practice Address - City:ASHMORE
Practice Address - State:IL
Practice Address - Zip Code:61912
Practice Address - Country:US
Practice Address - Phone:217-345-3206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X, 103TA0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical