Healthcare Provider Details

I. General information

NPI: 1558864082
Provider Name (Legal Business Name): MARLIE MARIE LIEBERMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARLIE MARIE VIPOND

II. Dates (important events)

Enumeration Date: 03/12/2018
Last Update Date: 03/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGN ST NE
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

3062 BURRITT ST NW
GRAND RAPIDS MI
49504-4686
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-1310
  • Fax: 616-391-3679
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501016370
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: