Healthcare Provider Details

I. General information

NPI: 1417066770
Provider Name (Legal Business Name): GLENN S LIEBERMAN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 LEROY STREET
BINGHAMTON NY
13905
US

IV. Provider business mailing address

16 LEROY STREET
BINGHAMTON NY
13905-4603
US

V. Phone/Fax

Practice location:
  • Phone: 607-765-0033
  • Fax: 607-217-7382
Mailing address:
  • Phone: 607-765-0033
  • Fax: 607-217-7382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR033334-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: