Healthcare Provider Details

I. General information

NPI: 1407479322
Provider Name (Legal Business Name): JOHN LIETTE AUD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2020
Last Update Date: 05/27/2020
Certification Date: 05/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 EAST BLVD
CLEVELAND OH
44106-1702
US

IV. Provider business mailing address

5455 N MARGINAL RD APT 405
CLEVELAND OH
44114-3947
US

V. Phone/Fax

Practice location:
  • Phone: 216-791-3800
  • Fax:
Mailing address:
  • Phone: 937-417-6499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberA.02253
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: