Provider Demographics
NPI:1376793182
Name:LIESFELD, JODY ELIZABETH (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:ELIZABETH
Last Name:LIESFELD
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 ROSENEATH RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23221-1515
Mailing Address - Country:US
Mailing Address - Phone:804-658-2973
Mailing Address - Fax:
Practice Address - Street 1:819 ROSENEATH RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23221-1515
Practice Address - Country:US
Practice Address - Phone:804-658-2973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-29
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-04-1856103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst