Provider Demographics
NPI:1760053953
Name:LISECKI, EDWARD III (BCBA)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:LISECKI
Suffix:III
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14415 E SMOKY HILL RD
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80015-1238
Mailing Address - Country:US
Mailing Address - Phone:720-524-7648
Mailing Address - Fax:
Practice Address - Street 1:14415 E SMOKY HILL RD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80015-1238
Practice Address - Country:US
Practice Address - Phone:720-524-7648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-21-48149103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst