Healthcare Provider Details

I. General information

NPI: 1235135179
Provider Name (Legal Business Name): MARK B. LIEBERT PT, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

69 FAIRWAY AVE
VERONA NJ
07044-1010
US

IV. Provider business mailing address

69 FAIRWAY AVE
VERONA NJ
07044-1010
US

V. Phone/Fax

Practice location:
  • Phone: 973-857-7004
  • Fax: 973-731-9728
Mailing address:
  • Phone: 973-857-7004
  • Fax: 973-731-9728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberQA 02933
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: