Healthcare Provider Details

I. General information

NPI: 1073804290
Provider Name (Legal Business Name): JOHN DAVID LIEBERMAN LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2011
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 MAIN ST
WEST HAVEN CT
06516-4296
US

IV. Provider business mailing address

415 MAIN ST
WEST HAVEN CT
06516-4296
US

V. Phone/Fax

Practice location:
  • Phone: 203-931-1184
  • Fax: 203-931-0063
Mailing address:
  • Phone: 203-931-1184
  • Fax: 203-931-0063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number002039
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: