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NPI Code Detail

MEDICARE: MR. SCOT LIEPACK PHD

MEDICARE: MR. SCOT LIEPACK PHD
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
1103T00000XPsychologistPSY722HI
2103TC0700XClinical PsychologistPSY1543NM
3103T00000XPsychologist4061AZ

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1912924853
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. SCOT LIEPACK PHD
Provider Business Mailing Address
First Line : PO BOX 26666
Second Line : PROVIDER ENROLLMENT
City : ALBUQUERQUE
State : NM
Zip : 87125-6666
Country : US
Telephone Number : 505-923-6770
Fax Number : 505-923-5354
Provider Business Practice Location Address
First Line : 6601 W THOMAS RD
Second Line :
City : PHOENIX
State : AZ
Zip : 85033-5700
Country : US
Telephone Number : 602-243-7277
Fax Number : 623-247-9742
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/16/2006
Last Update Date : 01/29/2019

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