Provider Demographics
NPI:1184465411
Name:LIEVENSE, ATHENA ELENA
Entity type:Individual
Prefix:
First Name:ATHENA
Middle Name:ELENA
Last Name:LIEVENSE
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 1:413 GEORGETOWN PKWY
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-3219
Mailing Address - Country:US
Mailing Address - Phone:517-375-7068
Mailing Address - Fax:
Practice Address - Street 1:413 GEORGETOWN PKWY
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-3219
Practice Address - Country:US
Practice Address - Phone:517-375-7068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program