Healthcare Provider Details

I. General information

NPI: 1750863833
Provider Name (Legal Business Name): MATTHEW LIEBENOW LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2018
Last Update Date: 04/29/2021
Certification Date: 04/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W175N11120 STONEWOOD DR
GERMANTOWN WI
53022-6511
US

IV. Provider business mailing address

W175N11120 STONEWOOD DR
GERMANTOWN WI
53022-6511
US

V. Phone/Fax

Practice location:
  • Phone: 262-345-5533
  • Fax: 262-293-9737
Mailing address:
  • Phone: 262-345-5533
  • Fax: 262-293-9737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number8167-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: