Healthcare Provider Details

I. General information

NPI: 1699343079
Provider Name (Legal Business Name): SUSAN LIEBERMAN A.M., LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2021
Last Update Date: 06/14/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12301 WHITEWATER DR STE 30
MINNETONKA MN
55343-4157
US

IV. Provider business mailing address

12301 WHITEWATER DR STE 30
MINNETONKA MN
55343-4157
US

V. Phone/Fax

Practice location:
  • Phone: 952-955-9018
  • Fax: 952-960-0869
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9811
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: