Healthcare Provider Details

I. General information

NPI: 1629567904
Provider Name (Legal Business Name): LIZA POTAPENKO PSY.D. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2018
Last Update Date: 05/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 DICKSON DR STE 10
AUSTIN TX
78704-4788
US

IV. Provider business mailing address

2111 DICKSON DR STE 10
AUSTIN TX
78704-4788
US

V. Phone/Fax

Practice location:
  • Phone: 512-710-7203
  • Fax:
Mailing address:
  • Phone: 512-710-7203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number36269
License Number StateTX

VIII. Authorized Official

Name: DR. ELIZAVETA POTAPENKO
Title or Position: PRESIDENT
Credential: PSY.D.
Phone: 512-710-7203