Provider Demographics
NPI:1457842858
Name:SACKS, LIAT DEBRA (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:LIAT
Middle Name:DEBRA
Last Name:SACKS
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 1:120 E SOUTH TOWN DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-4747
Mailing Address - Country:US
Mailing Address - Phone:903-630-7077
Mailing Address - Fax:903-630-6172
Practice Address - Street 1:14675 MIDWAY RD STE 208
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-3907
Practice Address - Country:US
Practice Address - Phone:903-630-7077
Practice Address - Fax:903-630-6172
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-18-29135103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst