Healthcare Provider Details

I. General information

NPI: 1699289736
Provider Name (Legal Business Name): EILEEN BETH LIEBLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2017
Last Update Date: 04/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

538 BROADHOLLOW RD STE 202
MELVILLE NY
11747-3668
US

IV. Provider business mailing address

763 PAT DR
WEST ISLIP NY
11795-3541
US

V. Phone/Fax

Practice location:
  • Phone: 631-385-7780
  • Fax:
Mailing address:
  • Phone: 516-233-0882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: