Provider Demographics
NPI:1861844813
Name:LIDDELL, JOE
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:
Last Name:LIDDELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JONAH
Other - Middle Name:RYAN
Other - Last Name:LIDDELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:408 SW MONROE AVE STE L101
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-7225
Mailing Address - Country:US
Mailing Address - Phone:541-243-3889
Mailing Address - Fax:
Practice Address - Street 1:408 SW MONROE AVE STE L101
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-7225
Practice Address - Country:US
Practice Address - Phone:541-243-3889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-01
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker