Provider Demographics
NPI:1386007276
Name:LIEZERT, EILEEN MARTHA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:EILEEN
Middle Name:MARTHA
Last Name:LIEZERT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N LONGWOOD ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-4134
Mailing Address - Country:US
Mailing Address - Phone:815-962-5585
Mailing Address - Fax:815-962-8945
Practice Address - Street 1:210 N LONGWOOD ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-4134
Practice Address - Country:US
Practice Address - Phone:815-962-5585
Practice Address - Fax:815-962-8945
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0010451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical