Healthcare Provider Details

I. General information

NPI: 1225954985
Provider Name (Legal Business Name): ANGIE LIEBERMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 HANCOCK ST
ELMONT NY
11003-1930
US

IV. Provider business mailing address

1405 HANCOCK ST
ELMONT NY
11003-1930
US

V. Phone/Fax

Practice location:
  • Phone: 517-564-2323
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: