Healthcare Provider Details

I. General information

NPI: 1275713398
Provider Name (Legal Business Name): DAVID T. LIEBERT ED.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 11/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 S FIELDING AVE
TAMPA FL
33606-2224
US

IV. Provider business mailing address

309 S FIELDING AVE
TAMPA FL
33606-2224
US

V. Phone/Fax

Practice location:
  • Phone: 813-546-1628
  • Fax:
Mailing address:
  • Phone: 813-546-1628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberMH5966
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: