Basic Information
| Provider Information | |||||||||
| NPI: | 1437203148 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIDDLE | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | F | ||||||||
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| Mailing Information | |||||||||
| Address1: | 675 TOWER AVENUE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061121256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607142750 | ||||||||
| FaxNumber: | 8607148591 | ||||||||
| Practice Location | |||||||||
| Address1: | 675 TOWER AVE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061121260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607142750 | ||||||||
| FaxNumber: | 8607148591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 000768 | CT | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.