Healthcare Provider Details

I. General information

NPI: 1972061760
Provider Name (Legal Business Name): MADELINE LIEBEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MADELINE INGRAM

II. Dates (important events)

Enumeration Date: 03/11/2019
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17B CALEDON CT
GREENVILLE SC
29615-3170
US

IV. Provider business mailing address

1321 MURFREESBORO PIKE STE 702
NASHVILLE TN
37217-2679
US

V. Phone/Fax

Practice location:
  • Phone: 864-631-2084
  • Fax:
Mailing address:
  • Phone: 615-724-4722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-78865
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: