Healthcare Provider Details

I. General information

NPI: 1538403613
Provider Name (Legal Business Name): RICHARD PAUL LIESKE MA, MDIV, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 08/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 HANNAH BLVD SUITE B-107
EAST LANSING MI
48823-5384
US

IV. Provider business mailing address

2900 HANNAH BLVD SUITE B-107
EAST LANSING MI
48823-5384
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-8087
  • Fax: 517-364-8088
Mailing address:
  • Phone: 517-364-8087
  • Fax: 517-364-8088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401006600
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401006600
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: