Healthcare Provider Details

I. General information

NPI: 1265174643
Provider Name (Legal Business Name): MICHAEL THOMAS LIEBHARD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2022
Last Update Date: 04/07/2022
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3530 CAMINO DEL RIO N STE 300
SAN DIEGO CA
92108-1746
US

IV. Provider business mailing address

3530 CAMINO DEL RIO N STE 300
SAN DIEGO CA
92108-1746
US

V. Phone/Fax

Practice location:
  • Phone: 619-791-2730
  • Fax: 619-470-4688
Mailing address:
  • Phone: 619-791-2730
  • Fax: 619-470-4688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: