Provider Demographics
NPI:1639194434
Name:LIPTAK, STEPHEN EDWARD (PSYD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:EDWARD
Last Name:LIPTAK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 N COUNTY ROAD 25A
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-1337
Mailing Address - Country:US
Mailing Address - Phone:937-440-7626
Mailing Address - Fax:937-440-7702
Practice Address - Street 1:3130 N COUNTY ROAD 25A
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-1337
Practice Address - Country:US
Practice Address - Phone:937-440-7626
Practice Address - Fax:937-440-7702
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4619103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHLICP77831Medicare ID - Type Unspecified