Healthcare Provider Details

I. General information

NPI: 1245781608
Provider Name (Legal Business Name): EVAN FREDRICK LIEBERMAN LADC, LGSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 11/29/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 SELBY AVENUE
SAINT PAUL MN
55102-5510
US

IV. Provider business mailing address

618 ADAMS ST NE # 1
MINNEAPOLIS MN
55413-2144
US

V. Phone/Fax

Practice location:
  • Phone: 847-721-5639
  • Fax:
Mailing address:
  • Phone: 847-721-5639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number303715
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number25758
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: