Provider Demographics
NPI:1689659526
Name:LIETHEN, PHILIP CHARLES (PHD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:CHARLES
Last Name:LIETHEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2616 WHITNEY PL
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3952
Mailing Address - Country:US
Mailing Address - Phone:586-246-5746
Mailing Address - Fax:
Practice Address - Street 1:2616 WHITNEY PL
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3952
Practice Address - Country:US
Practice Address - Phone:586-246-5746
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3063103G00000X
WI2082103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N38250Medicare ID - Type UnspecifiedMEDICARE-PORT HURON
MI0N38240Medicare ID - Type UnspecifiedMEDICARE-CLINTON TOWNSHIP