Healthcare Provider Details

I. General information

NPI: 1235221292
Provider Name (Legal Business Name): VICTOR LEWIS LIEBERMAN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 S 4TH ST W
MISSOULA MT
59801-2630
US

IV. Provider business mailing address

PO BOX 7275
MISSOULA MT
59807-7275
US

V. Phone/Fax

Practice location:
  • Phone: 406-327-8830
  • Fax: 406-542-0787
Mailing address:
  • Phone: 406-327-8830
  • Fax: 406-542-0787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number308
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: