Provider Demographics
NPI:1851756951
Name:PAVOGGI, LIESA
Entity Type:Individual
Prefix:
First Name:LIESA
Middle Name:
Last Name:PAVOGGI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 ACORN LN
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-5001
Mailing Address - Country:US
Mailing Address - Phone:254-781-6288
Mailing Address - Fax:
Practice Address - Street 1:265 ACORN LN
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-5001
Practice Address - Country:US
Practice Address - Phone:254-781-6288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-16
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX71045101Y00000X
TX12300101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1487913711OtherUNITED STATES ARMY