Provider Demographics
NPI:1295276731
Name:LIETCH, SHANE
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:
Last Name:LIETCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11998 E 223RD ST S
Mailing Address - Street 2:
Mailing Address - City:PORUM
Mailing Address - State:OK
Mailing Address - Zip Code:74455-4081
Mailing Address - Country:US
Mailing Address - Phone:405-588-2356
Mailing Address - Fax:
Practice Address - Street 1:609 ROLLING HILLS TER
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73012-6611
Practice Address - Country:US
Practice Address - Phone:405-588-2356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-16
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator