Healthcare Provider Details

I. General information

NPI: 1447858907
Provider Name (Legal Business Name): TIMOTHY LIESER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2020
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3405 DALLAS HWY SW STE 601
MARIETTA GA
30064-6427
US

IV. Provider business mailing address

3405 DALLAS HWY SW STE 601
MARIETTA GA
30064-6427
US

V. Phone/Fax

Practice location:
  • Phone: 770-438-5226
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT015009
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: