Healthcare Provider Details

I. General information

NPI: 1770801631
Provider Name (Legal Business Name): JUDITH ELAINE LIEBESPACH LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2010
Last Update Date: 05/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 S KINGS AVE
BRANDON FL
33511-5922
US

IV. Provider business mailing address

1832 S RIDGE DR
VALRICO FL
33594-5547
US

V. Phone/Fax

Practice location:
  • Phone: 813-857-5871
  • Fax:
Mailing address:
  • Phone: 813-653-0459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License NumberMA10753
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: