Healthcare Provider Details

I. General information

NPI: 1114063138
Provider Name (Legal Business Name): BRANDIE P. LIEBLONG PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 GLENDALE ST
JONESBORO AR
72401-4455
US

IV. Provider business mailing address

3507 WOODSPRINGS RD
JONESBORO AR
72404-6808
US

V. Phone/Fax

Practice location:
  • Phone: 870-933-9528
  • Fax: 870-933-9778
Mailing address:
  • Phone: 870-931-1818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2132
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: