Healthcare Provider Details

I. General information

NPI: 1316121510
Provider Name (Legal Business Name): MS. SANDY K LIEBERUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 12/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15870 ROUTE 322 STE. 2
CLARION PA
16214-6376
US

IV. Provider business mailing address

15870 ROUTE 322 STE. 2
CLARION PA
16214
US

V. Phone/Fax

Practice location:
  • Phone: 814-764-6066
  • Fax: 814-764-5669
Mailing address:
  • Phone: 814-764-6066
  • Fax: 814-764-5669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1012910120001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: