Healthcare Provider Details

I. General information

NPI: 1053654210
Provider Name (Legal Business Name): JESSICA LIEBERTH PC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2013
Last Update Date: 04/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8445 MUNSON RD
MENTOR OH
44060-2410
US

IV. Provider business mailing address

8445 MUNSON RD
MENTOR OH
44060-2410
US

V. Phone/Fax

Practice location:
  • Phone: 440-255-1700
  • Fax: 440-205-2417
Mailing address:
  • Phone: 440-255-1700
  • Fax: 440-205-2417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC0900249
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: