Healthcare Provider Details

I. General information

NPI: 1699640268
Provider Name (Legal Business Name): CHASE LIEBLEIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2025
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3454 ZAFARANO DR
SANTA FE NM
87507-2666
US

IV. Provider business mailing address

411 N NEW RIVER DR E APT 2401
FORT LAUDERDALE FL
33301-8114
US

V. Phone/Fax

Practice location:
  • Phone: 505-216-5008
  • Fax:
Mailing address:
  • Phone: 954-552-9637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-2025-0291
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: