MEDICARE: JOSEPH MATTHEW LIESTENFELTZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		MI

General Provider Information

NPI Number	:	1023544228
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSEPH MATTHEW LIESTENFELTZ

Provider Business Mailing Address
First Line	:	6021 W SANBORN RD
Second Line	:
City	:	LAKE CITY
State	:	MI
Zip	:	49651-9250
Country	:	US
Telephone Number	:	231-920-3623
Fax Number	:

Provider Business Practice Location Address
First Line	:	6021 W SANBORN RD
Second Line	:
City	:	LAKE CITY
State	:	MI
Zip	:	49651-9250
Country	:	US
Telephone Number	:	231-920-3623
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2017
Last Update Date	:	05/08/2017

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