Healthcare Provider Details

I. General information

NPI: 1750898730
Provider Name (Legal Business Name): LAURA STACY LIEBERMAN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2017
Last Update Date: 12/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2728 BEACH DR
MERRICK NY
11566-4902
US

IV. Provider business mailing address

2728 BEACH DR
MERRICK NY
11566-4902
US

V. Phone/Fax

Practice location:
  • Phone: 516-382-2270
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1001796
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: