Healthcare Provider Details

I. General information

NPI: 1508876962
Provider Name (Legal Business Name): LARRY LIEBGOLD LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 03/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10800 SIKES PL STE 300
CHARLOTTE NC
28277-8124
US

IV. Provider business mailing address

1615 RIVER BEND BLVD
INDIAN LAND SC
29707-5523
US

V. Phone/Fax

Practice location:
  • Phone: 720-530-0500
  • Fax:
Mailing address:
  • Phone: 720-530-0500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number13662
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number13997
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: