Healthcare Provider Details

I. General information

NPI: 1194548560
Provider Name (Legal Business Name): PHILLIP MAXWELL LIEBERMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2024
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10650 E BETHANY DRIVE
AURORA CO
80014
US

IV. Provider business mailing address

115 W CHEYENNE RD APT 311
COLORADO SPRINGS CO
80906-2510
US

V. Phone/Fax

Practice location:
  • Phone: 719-203-4723
  • Fax:
Mailing address:
  • Phone: 918-780-0619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: