Provider Demographics
NPI:1043614977
Name:LIEDKE, LARRY
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:LIEDKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 W MAIN ST
Mailing Address - Street 2:SUIT B
Mailing Address - City:WAUCHULA
Mailing Address - State:FL
Mailing Address - Zip Code:33873-2819
Mailing Address - Country:US
Mailing Address - Phone:863-448-4332
Mailing Address - Fax:
Practice Address - Street 1:125 W MAIN ST
Practice Address - Street 2:SUIT B
Practice Address - City:WAUCHULA
Practice Address - State:FL
Practice Address - Zip Code:33873-2819
Practice Address - Country:US
Practice Address - Phone:863-448-4332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)