Provider Demographics
NPI:1770676223
Name:LIESE, BRUCE S (PHD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:S
Last Name:LIESE
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:PO BOX 411851
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64141-1851
Mailing Address - Country:US
Mailing Address - Phone:913-588-1944
Mailing Address - Fax:913-588-2496
Practice Address - Street 1:3901 RAINBOW BLVD
Practice Address - Street 2:MS 4017
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160-0001
Practice Address - Country:US
Practice Address - Phone:913-588-1944
Practice Address - Fax:913-588-2496
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0616103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO498634500Medicaid
110150074OtherRAILROAD MEDICARE
11784036OtherBCBS KANSAS CITY
KS4957111501Medicaid
MO498634500Medicaid
R77287Medicare UPIN