Healthcare Provider Details

I. General information

NPI: 1760155741
Provider Name (Legal Business Name): JOSHUA MARC LIEBERMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2021
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 MAPLE ST
SPRINGFIELD MA
01105-1864
US

IV. Provider business mailing address

110 MAPLE ST
SPRINGFIELD MA
01105-1864
US

V. Phone/Fax

Practice location:
  • Phone: 413-732-7419
  • Fax: 413-781-1059
Mailing address:
  • Phone: 413-732-7419
  • Fax: 413-781-1059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: