Provider Demographics
NPI:1144778994
Name:LIEDERBACH, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:LIEDERBACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2474 E JOYCE BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4932
Mailing Address - Country:US
Mailing Address - Phone:479-521-8326
Mailing Address - Fax:
Practice Address - Street 1:2474 E JOYCE BLVD STE 2
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4932
Practice Address - Country:US
Practice Address - Phone:479-521-8326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT4200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist