Basic Information
| Provider Information | |||||||||
| NPI: | 1629622105 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIEBETREU | ||||||||
| FirstName: | AJIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 31557 SCHOOLCRAFT RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481501848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344742958 | ||||||||
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| Practice Location | |||||||||
| Address1: | 31558 SCHOOLCRAFT RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481501805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344742958 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2019 | ||||||||
| LastUpdateDate: | 08/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | MI | Y | 106S00000X | N |
No ID Information.