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General NPI Number Information
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NPI Number | 1487779575
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Entity Type | Organization
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Legal Business Name | THEODORE R. LIAUTAUD
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Dates
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Enumeration Date | 03/20/2007
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Last Update Date | 09/30/2008
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Provider Practice Location Address
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Address Line | 421 E SHORE DR
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City | LAKE VIEW
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State | IA
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Zip | 51450
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Country | US
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Telephone | 712-657-2211
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Fax | 712-657-2106
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Provider Business Mailing Address
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Address Line | PO BOX 710 421 E SHORE DR
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City | LAKE VIEW
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State | IA
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Zip | 51450
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Country | US
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Telephone | 712-657-2211
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Fax | 712-657-2106
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Authorized Official
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Title or Position | OWNER
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Name | THEODORE R. LIAUTAUD
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Credential | DO
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Telephone | 712-657-2211
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 01790
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License Number State | IA
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 01790
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License Number State | IA
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