Healthcare Provider Details

I. General information

NPI: 1023019544
Provider Name (Legal Business Name): THADDEUS R LIEBIG PT, DPT,ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 07/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W DARLENE ST
HARTINGTON NE
68739-4510
US

IV. Provider business mailing address

401 W DARLENE ST PO BOX 107
HARTINGTON NE
68739-4510
US

V. Phone/Fax

Practice location:
  • Phone: 402-254-3985
  • Fax: 402-254-3963
Mailing address:
  • Phone: 402-254-3985
  • Fax: 402-254-3963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1065
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number1668
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: