Healthcare Provider Details

I. General information

NPI: 1841293057
Provider Name (Legal Business Name): KENNETH LIEBENAU PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 08/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

727 N WACO AVE STE 320
WICHITA KS
67203-3972
US

IV. Provider business mailing address

727 N WACO AVE STE 320
WICHITA KS
67203-3972
US

V. Phone/Fax

Practice location:
  • Phone: 316-616-0260
  • Fax: 316-616-0264
Mailing address:
  • Phone: 316-616-0260
  • Fax: 316-616-0264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP-1019
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: