Provider Demographics
NPI:1871030049
Name:LIEDERBACH, BROOKS MARIE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:BROOKS
Middle Name:MARIE
Last Name:LIEDERBACH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:BROOKS
Other - Middle Name:MARIE
Other - Last Name:CLINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:1451 LUCAS RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-8682
Mailing Address - Country:US
Mailing Address - Phone:419-589-5511
Mailing Address - Fax:419-589-7381
Practice Address - Street 1:1451 LUCAS RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-8682
Practice Address - Country:US
Practice Address - Phone:419-589-5511
Practice Address - Fax:419-589-7381
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH138428.MEDS-IV323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility