Provider Demographics
NPI:1437106150
Name:LIETZKE, DOUGLAS (PSYCHOLOGIST)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:
Last Name:LIETZKE
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1446 FARMINGTON AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:POTTSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19464-1892
Mailing Address - Country:US
Mailing Address - Phone:610-323-8844
Mailing Address - Fax:610-987-0276
Practice Address - Street 1:1446 FARMINGTON AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:POTTSTOWN
Practice Address - State:PA
Practice Address - Zip Code:19464-1892
Practice Address - Country:US
Practice Address - Phone:610-323-8844
Practice Address - Fax:610-987-0276
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS000394L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist