Healthcare Provider Details

I. General information

NPI: 1962713966
Provider Name (Legal Business Name): KATHERINE VALERIE LIEBESNY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2010
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2017 JEFFERSON ST SW
ROANOKE VA
24014-2419
US

IV. Provider business mailing address

2017 JEFFERSON ST SW
ROANOKE VA
24014-2419
US

V. Phone/Fax

Practice location:
  • Phone: 540-981-8960
  • Fax: 540-853-0511
Mailing address:
  • Phone: 540-981-8960
  • Fax: 540-853-0511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberLP02052
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: