Provider Demographics
NPI:1003824343
Name:LIEDTKEHENDRICKSON, VALETTE ----------- (PHD)
Entity Type:Individual
Prefix:
First Name:VALETTE
Middle Name:-----------
Last Name:LIEDTKEHENDRICKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:493 W HARWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-2943
Mailing Address - Country:US
Mailing Address - Phone:817-280-0444
Mailing Address - Fax:817-280-0188
Practice Address - Street 1:493 W HARWOOD RD
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-2943
Practice Address - Country:US
Practice Address - Phone:817-280-0444
Practice Address - Fax:817-280-0188
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX2943103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical