Healthcare Provider Details

I. General information

NPI: 1619152857
Provider Name (Legal Business Name): BRIAN ALAN LIETZ BA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2008
Last Update Date: 02/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 15TH ST NW
BEMIDJI MN
56601-2528
US

IV. Provider business mailing address

722 15TH ST NW P.O. BOX 640
BEMIDJI MN
56601-2528
US

V. Phone/Fax

Practice location:
  • Phone: 218-751-3280
  • Fax:
Mailing address:
  • Phone: 218-751-3280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: