Healthcare Provider Details

I. General information

NPI: 1881965424
Provider Name (Legal Business Name): GOLDIE B LIEBES MS CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GOLDIE B PINE MS CCC-SLP

II. Dates (important events)

Enumeration Date: 01/12/2012
Last Update Date: 01/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2409 SHELLEYDALE DR
BALTIMORE MD
21209-3209
US

IV. Provider business mailing address

2409 SHELLEYDALE DR
BALTIMORE MD
21209-3209
US

V. Phone/Fax

Practice location:
  • Phone: 443-310-3469
  • Fax: 443-276-5857
Mailing address:
  • Phone: 443-310-3469
  • Fax: 443-276-5857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number04367
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: