Provider Demographics
NPI:1992709448
Name:LITZENBERGER, BRIAN WAYNE (PHD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:WAYNE
Last Name:LITZENBERGER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-2505
Mailing Address - Country:US
Mailing Address - Phone:508-767-1809
Mailing Address - Fax:508-755-8645
Practice Address - Street 1:9 CEDAR ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-2505
Practice Address - Country:US
Practice Address - Phone:508-767-1809
Practice Address - Fax:508-755-8645
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7573103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW50602Medicare ID - Type UnspecifiedMEDICARE NUMBER