Provider Demographics
NPI:1437203148
Name:LIDDLE, JEFFREY F
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:F
Last Name:LIDDLE
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 1:675 TOWER AVENUE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06112-1256
Mailing Address - Country:US
Mailing Address - Phone:860-714-2750
Mailing Address - Fax:860-714-8591
Practice Address - Street 1:675 TOWER AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06112-1260
Practice Address - Country:US
Practice Address - Phone:860-714-2750
Practice Address - Fax:860-714-8591
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000768101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional