Provider Demographics
NPI:1164910865
Name:LIDDICOET, DANIEL EVANS
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:EVANS
Last Name:LIDDICOET
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 1:2310 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-2835
Mailing Address - Country:US
Mailing Address - Phone:770-634-4697
Mailing Address - Fax:
Practice Address - Street 1:3645 E MCLEOD RD
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-8700
Practice Address - Country:US
Practice Address - Phone:360-676-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst