Provider Demographics
NPI:1972043669
Name:CAROL LIESER PMHNP PLLC
Entity Type:Organization
Organization Name:CAROL LIESER PMHNP PLLC
Other - Org Name:IN HIS IMAGE PSYCHIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PSYCH MENTAL HEALTH NURSE PRA
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:LIESER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD APRN PMHNP BC
Authorized Official - Phone:817-914-4168
Mailing Address - Street 1:4425 W AIRPORT FWY
Mailing Address - Street 2:STE 244
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062
Mailing Address - Country:US
Mailing Address - Phone:972-252-2945
Mailing Address - Fax:888-975-2092
Practice Address - Street 1:4425 W AIRPORT FWY
Practice Address - Street 2:STE 244
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062
Practice Address - Country:US
Practice Address - Phone:972-252-2945
Practice Address - Fax:888-975-2092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
462622/AP108300363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXNP7659OtherBC/BS