Healthcare Provider Details

I. General information

NPI: 1891169934
Provider Name (Legal Business Name): MARLEY LIEBERMAN IMF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2015
Last Update Date: 11/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3760 CONVOY ST STE 118
SAN DIEGO CA
92111-3743
US

IV. Provider business mailing address

3760 CONVOY ST STE 118
SAN DIEGO CA
92111-3743
US

V. Phone/Fax

Practice location:
  • Phone: 619-736-7013
  • Fax: 858-292-0143
Mailing address:
  • Phone: 619-736-7013
  • Fax: 858-292-0143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number106520
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: