Basic Information
Provider Information | |||||||||
NPI: | 1386160356 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LIPTAK | ||||||||
FirstName: | JOSEPH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CDCA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 429 | ||||||||
Address2: |   | ||||||||
City: | LISBON | ||||||||
State: | OH | ||||||||
PostalCode: | 444320429 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3304249573 | ||||||||
FaxNumber: | 3304240877 | ||||||||
Practice Location | |||||||||
Address1: | 40722 STATE ROUTE 154 | ||||||||
Address2: |   | ||||||||
City: | LISBON | ||||||||
State: | OH | ||||||||
PostalCode: | 444328500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3304249573 | ||||||||
FaxNumber: | 3304240877 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/21/2017 | ||||||||
LastUpdateDate: | 08/21/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CDCA.120820 | OH | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
ID | Type | State | Issuer | Description | CDCA.120820 | 01 | ND | CHEMICAL DEPENDENCY BOARD | OTHER |