Provider Demographics
NPI:1790132314
Name:LIEDTKE, SARA (LMHC)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:LIEDTKE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 FARADAY ST APT 4
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14610-1763
Mailing Address - Country:US
Mailing Address - Phone:585-478-2560
Mailing Address - Fax:
Practice Address - Street 1:1387 FAIRPORT RD STE 504
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-2003
Practice Address - Country:US
Practice Address - Phone:585-478-2560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-24
Last Update Date:2019-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9880547101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health