Healthcare Provider Details

I. General information

NPI: 1902217243
Provider Name (Legal Business Name): RUTH LIEBERMAN R.N, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2014
Last Update Date: 01/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3930 RICHMOND AVE SUITE 104
STATEN ISLAND NY
10312
US

IV. Provider business mailing address

175 ZOE ST APT. 5B
STATEN ISLAND NY
10305-1101
US

V. Phone/Fax

Practice location:
  • Phone: 917-502-5210
  • Fax:
Mailing address:
  • Phone: 917-502-5210
  • Fax: 718-948-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP92495
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number481182
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number006907-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: