Healthcare Provider Details

I. General information

NPI: 1679984595
Provider Name (Legal Business Name): KAITLIN LECKIE PHD, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 09/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 UNIVERSITY BLVD
GALVESTON TX
77555-1385
US

IV. Provider business mailing address

301 UNIVERSITY BLVD
GALVESTON TX
77555-1385
US

V. Phone/Fax

Practice location:
  • Phone: 409-772-2166
  • Fax: 409-772-2663
Mailing address:
  • Phone: 409-772-2166
  • Fax: 409-772-2663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: