Healthcare Provider Details

I. General information

NPI: 1518356963
Provider Name (Legal Business Name): CYNTHIA LIESKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2015
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 NORTHLAND DRIVE
ROCKFORD MI
49341
US

IV. Provider business mailing address

6077 MOLLI DR
ALLENDALE MI
49401-9219
US

V. Phone/Fax

Practice location:
  • Phone: 616-805-3660
  • Fax:
Mailing address:
  • Phone: 517-980-3129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851099055
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: