Provider Demographics
NPI:1053854778
Name:LIAROMATIS, KATHERINE SUE (SAC-IT 17948-130)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:SUE
Last Name:LIAROMATIS
Suffix:
Gender:F
Credentials:SAC-IT 17948-130
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1612 VOGT DR
Mailing Address - Street 2:APARTMENT 102
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-8517
Mailing Address - Country:US
Mailing Address - Phone:920-344-9495
Mailing Address - Fax:
Practice Address - Street 1:1622 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-3014
Practice Address - Country:US
Practice Address - Phone:262-306-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)