Healthcare Provider Details

I. General information

NPI: 1851282248
Provider Name (Legal Business Name): JOSH LIEBELT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2025
Last Update Date: 07/14/2025
Certification Date: 07/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3665 N BROADWAY ST
CHICAGO IL
60613-4567
US

IV. Provider business mailing address

839 W DIVERSEY PKWY APT 406
CHICAGO IL
60614-1449
US

V. Phone/Fax

Practice location:
  • Phone: 773-496-4433
  • Fax:
Mailing address:
  • Phone: 414-308-3010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: