Healthcare Provider Details

I. General information

NPI: 1427379163
Provider Name (Legal Business Name): ELIZABETH ROSE LIEBERMAN BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2010
Last Update Date: 06/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 RAVINE DR APT 16B
MATAWAN NJ
07747-2872
US

IV. Provider business mailing address

130 RAVINE DR APT 16B
MATAWAN NJ
07747-2872
US

V. Phone/Fax

Practice location:
  • Phone: 732-970-5685
  • Fax:
Mailing address:
  • Phone: 732-970-5685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-08-4780
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: