Provider Demographics
NPI:1710349311
Name:FENNO, LIEF ERICSSON (MD)
Entity Type:Individual
Prefix:
First Name:LIEF
Middle Name:ERICSSON
Last Name:FENNO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 TRINITY STREET, BLDG. B
Mailing Address - Street 2:HDB 3, Z0600
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78712-1419
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1601 TRINITY STREET, BLDG. B
Practice Address - Street 2:HDB 3, Z0600
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78712-1419
Practice Address - Country:US
Practice Address - Phone:833-882-2737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2022-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1510302084P0800X, 2084P0802X
TXT51322084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry