Provider Demographics
NPI:1366210163
Name:LEENKNECHT, TYLER PAUL
Entity type:Individual
Prefix:MR
First Name:TYLER
Middle Name:PAUL
Last Name:LEENKNECHT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1662
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83680
Mailing Address - Country:US
Mailing Address - Phone:208-571-8459
Mailing Address - Fax:208-315-6718
Practice Address - Street 1:1407 W. MCMILLAN ROAD
Practice Address - Street 2:SUITE 120
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646
Practice Address - Country:US
Practice Address - Phone:208-315-6717
Practice Address - Fax:208-315-6718
Is Sole Proprietor?:No
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator