Healthcare Provider Details

I. General information

NPI: 1235333667
Provider Name (Legal Business Name): CHAITRA WIRTA-LEIKER PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 04/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 AIRPORT PKWY SUITE 120
CHEYENNE WY
82001-1518
US

IV. Provider business mailing address

1401 AIRPORT PKWY SUITE 120
CHEYENNE WY
82001-1518
US

V. Phone/Fax

Practice location:
  • Phone: 307-632-7771
  • Fax:
Mailing address:
  • Phone: 307-632-7771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number515
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number515
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number515
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: