MEDICARE: KELLY LIEBEL

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1578812046
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY LIEBEL

Provider Business Mailing Address
First Line	:	1100 N D ST
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92410-3524
Country	:	US
Telephone Number	:	909-381-3774
Fax Number	:

Provider Business Practice Location Address
First Line	:	1149 N D ST
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92410-3523
Country	:	US
Telephone Number	:	909-571-6035
Fax Number	:	909-571-6333

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

Provider Enumeration Date	:	08/30/2012
Last Update Date	:	06/21/2019

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Directions to “ KELLY LIEBEL ” Practice Location

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