Provider Demographics
NPI:1104270164
Name:WEBER, LIZA AMANDA
Entity type:Individual
Prefix:
First Name:LIZA
Middle Name:AMANDA
Last Name:WEBER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 RESEARCH CT STE 800
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6606
Mailing Address - Country:US
Mailing Address - Phone:678-749-7600
Mailing Address - Fax:
Practice Address - Street 1:5050 RESEARCH CT STE 800
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6606
Practice Address - Country:US
Practice Address - Phone:678-749-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-15
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004379103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist