Healthcare Provider Details

I. General information

NPI: 1043528235
Provider Name (Legal Business Name): HESTER SIQUILLA LIEBETRAU PSYD, HSPP, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2010
Last Update Date: 01/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 N HARRISON ST
WARSAW IN
46580-3163
US

IV. Provider business mailing address

850 N HARRISON ST ATTN: ANNE LAWSON
WARSAW IN
46580-3163
US

V. Phone/Fax

Practice location:
  • Phone: 574-267-7169
  • Fax: 574-269-5573
Mailing address:
  • Phone: 574-267-7878
  • Fax: 574-269-5573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20042665A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: