Provider Demographics
NPI:1912062191
Name:LIOTTA, RICHARD F (PHD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:F
Last Name:LIOTTA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 229
Mailing Address - Street 2:703 COUNTY RTE 60
Mailing Address - City:RAINBOW LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12976-0229
Mailing Address - Country:US
Mailing Address - Phone:518-327-3702
Mailing Address - Fax:518-327-3092
Practice Address - Street 1:88 WOODRUFF ST
Practice Address - Street 2:
Practice Address - City:SARANAC LAKE
Practice Address - State:NY
Practice Address - Zip Code:12983-1713
Practice Address - Country:US
Practice Address - Phone:518-891-0924
Practice Address - Fax:518-327-3092
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010490103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBB9087Medicare ID - Type Unspecified
NYBB3893Medicare ID - Type Unspecified
NY573329Medicare UPIN