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General NPI Number Information
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NPI Number | 1285188110
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Entity Type | Individual
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Provider Name | JUSTIN J LIBERTA MS, LAT, ATC, CES
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Gender | Male
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Dates
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Enumeration Date | 08/09/2016
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Last Update Date | 07/08/2018
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Provider Practice Location Address
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Address Line | 501 E 38TH ST
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City | ERIE
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State | PA
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Zip | 16546
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Country | US
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Telephone | 716-848-9503
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Fax |
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Provider Business Mailing Address
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Address Line | 4227 ALPENHORN DR NW # APRT2
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City | COMSTOCK PARK
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State | MI
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Zip | 49321-8628
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Country | US
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Telephone | 716-848-9503
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | RT006351
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License Number State | PA
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