=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750579579
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIZA YORK, PH.D., LPPC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2007
-----------------------------------------------------
Last Update Date | 10/05/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 703 3RD AVE SUITE C
-----------------------------------------------------
City | LONGMONT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80501-5996
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-875-4158
-----------------------------------------------------
Fax | 303-776-7631
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 703 3RD AVE SUITE C
-----------------------------------------------------
City | LONGMONT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80501-5996
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-875-4158
-----------------------------------------------------
Fax | 303-776-7631
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | DR. LIZA L YORK
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 303-875-4158
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 2475
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 2475
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------