=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316937782
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY LIEBOW D.P.M.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2005
-----------------------------------------------------
Last Update Date | 05/09/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 382 CANAL ST
-----------------------------------------------------
City | BRATTLEBORO
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05301-6617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-254-0202
-----------------------------------------------------
Fax | 802-246-1300
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 910
-----------------------------------------------------
City | GREENFIELD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01302-0910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-772-8500
-----------------------------------------------------
Fax | 413-772-8900
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 0560000167
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------