Provider Demographics
NPI:1659392843
Name:LIEDEL, JULIE
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:LIEDEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13840 KAHLA DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111-1033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18285 E 10 MILE RD
Practice Address - Street 2:STE.100
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-5802
Practice Address - Country:US
Practice Address - Phone:586-774-5774
Practice Address - Fax:586-774-5884
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201003175225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00363458OtherRAILROAD
MIP00081958OtherRAILROAD
MI670H202840OtherBCBS
MI670H215940OtherBCBS
MIP00363458OtherRAILROAD
MI670H202840OtherBCBS