Healthcare Provider Details

I. General information

NPI: 1164681839
Provider Name (Legal Business Name): KATHRYN LAUREN LIEBENBERG PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2008
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 KINGS HWY N
WESTPORT CT
06880-2443
US

IV. Provider business mailing address

166 KINGS HWY N
WESTPORT CT
06880-2443
US

V. Phone/Fax

Practice location:
  • Phone: 646-734-6672
  • Fax:
Mailing address:
  • Phone: 646-734-6672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number017563-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number002997
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: