Healthcare Provider Details

I. General information

NPI: 1972876266
Provider Name (Legal Business Name): SUSAN LIEBERT MS, RD, CNSC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2012
Last Update Date: 02/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5127 WINDHAM WAY
ROCKLIN CA
95765-5307
US

IV. Provider business mailing address

5127 WINDHAM WAY
ROCKLIN CA
95765-5307
US

V. Phone/Fax

Practice location:
  • Phone: 916-412-7811
  • Fax:
Mailing address:
  • Phone: 916-412-7811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number971628
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: