Healthcare Provider Details

I. General information

NPI: 1508573502
Provider Name (Legal Business Name): LIBERATE THE BLOCK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2022
Last Update Date: 10/31/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1329 MILTON ST
PITTSBURGH PA
15218-1234
US

IV. Provider business mailing address

1329 MILTON ST
PITTSBURGH PA
15218-1234
US

V. Phone/Fax

Practice location:
  • Phone: 412-437-8687
  • Fax:
Mailing address:
  • Phone: 412-437-8687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QR1100X
TaxonomyResearch Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LEI WANG
Title or Position: CHIEF OF OPERATIONS
Credential: PH.D.
Phone: 412-437-8687