Basic Information
| Provider Information | |||||||||
| NPI: | 1942266580 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIQUETE | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 213 S JEFFERSON ST STE 625 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240111713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402245516 | ||||||||
| FaxNumber: | 5402245684 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 TYLER RD | ||||||||
| Address2: | |||||||||
| City: | CHRISTIANSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240736374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407317311 | ||||||||
| FaxNumber: | 5407317377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 39490 | TN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 0101244357 | VA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 3331589 | 05 | TN | MEDICAID | 4114432 | 01 | TN | BCBS | OTHER | 3331581 | 05 | TN | MEDICAID | 1435-320 | 05 | WI | MEDICAID |