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General NPI Number Information
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NPI Number | 1629567904
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Entity Type | Organization
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Legal Business Name | LIZA POTAPENKO PSY.D. LLC
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Dates
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Enumeration Date | 05/02/2018
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Last Update Date | 05/02/2018
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Provider Practice Location Address
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Address Line | 2111 DICKSON DR STE 10
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City | AUSTIN
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State | TX
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Zip | 78704-4788
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Country | US
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Telephone | 512-710-7203
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Fax |
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Provider Business Mailing Address
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Address Line | 2111 DICKSON DR STE 10
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City | AUSTIN
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State | TX
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Zip | 78704-4788
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Country | US
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Telephone | 512-710-7203
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ELIZAVETA POTAPENKO
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Credential | PSY.D.
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Telephone | 512-710-7203
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 36269
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License Number State | TX
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