Healthcare Provider Details

I. General information

NPI: 1659459956
Provider Name (Legal Business Name): LORI FRAN LIEBERMAN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 WILLARD ST STE 2F
QUINCY MA
02169-1274
US

IV. Provider business mailing address

111 WILLARD ST STE 2F
QUINCY MA
02169-1274
US

V. Phone/Fax

Practice location:
  • Phone: 781-335-7559
  • Fax: 781-331-6410
Mailing address:
  • Phone: 781-335-7559
  • Fax: 781-331-6410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number743
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: