Provider Demographics
NPI:1295390813
Name:LIDDELL, ANNE (ATR-BC, LCAT)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:
Last Name:LIDDELL
Suffix:
Gender:F
Credentials:ATR-BC, LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 RAILROAD AVE UNIT 1103
Mailing Address - Street 2:
Mailing Address - City:COPIAGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11726-2725
Mailing Address - Country:US
Mailing Address - Phone:516-946-4268
Mailing Address - Fax:
Practice Address - Street 1:49 WYCKOFF AVE APT 401
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-2652
Practice Address - Country:US
Practice Address - Phone:347-871-5931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-08
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002015-1221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist