Individual
MR. SHANE LIETCH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
609 ROLLING HILLS TER, EDMOND, OK 73012-6611
(405) 588-2356
Mailing address
11998 E 223RD ST S, PORUM, OK 74455-4081
(405) 588-2356
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
—
—
175T00000X
Peer Specialist
Primary
—
—
Other
Enumeration date
03/16/2017
Last updated
04/18/2022
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