Healthcare Provider Details

I. General information

NPI: 1023544228
Provider Name (Legal Business Name): JOSEPH MATTHEW LIESTENFELTZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2017
Last Update Date: 05/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6021 W SANBORN RD
LAKE CITY MI
49651-9250
US

IV. Provider business mailing address

6021 W SANBORN RD
LAKE CITY MI
49651-9250
US

V. Phone/Fax

Practice location:
  • Phone: 231-920-3623
  • Fax:
Mailing address:
  • Phone: 231-920-3623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: