MEDICARE: MARK B. LIEBERT PT, PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	QA 02933	NJ

General Provider Information

NPI Number	:	1235135179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK B. LIEBERT PT, PHD

Provider Business Mailing Address
First Line	:	69 FAIRWAY AVE
Second Line	:
City	:	VERONA
State	:	NJ
Zip	:	07044-1010
Country	:	US
Telephone Number	:	973-857-7004
Fax Number	:	973-731-9728

Provider Business Practice Location Address
First Line	:	69 FAIRWAY AVE
Second Line	:
City	:	VERONA
State	:	NJ
Zip	:	07044-1010
Country	:	US
Telephone Number	:	973-857-7004
Fax Number	:	973-731-9728

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2005
Last Update Date	:	07/08/2007

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