Healthcare Provider Details

I. General information

NPI: 1346013042
Provider Name (Legal Business Name): AVITAL LIBERZON ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2023
Last Update Date: 08/29/2026
Certification Date: 08/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 MERCER ST
NEW YORK NY
10012-1501
US

IV. Provider business mailing address

5424 RIVERSIDE STATION BLVD
SECAUCUS NJ
07094-4454
US

V. Phone/Fax

Practice location:
  • Phone: 212-998-2073
  • Fax:
Mailing address:
  • Phone: 617-694-7115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number005023-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberATL22160
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: