Provider Demographics
NPI:1033266069
Name:PORTE-LIEBERMAN, CAROLYN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:
Last Name:PORTE-LIEBERMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:489 KNICKERBOCKER RD
Mailing Address - Street 2:
Mailing Address - City:TENAFLY
Mailing Address - State:NJ
Mailing Address - Zip Code:07670-1452
Mailing Address - Country:US
Mailing Address - Phone:201-567-4983
Mailing Address - Fax:
Practice Address - Street 1:121 CEDAR LN
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4457
Practice Address - Country:US
Practice Address - Phone:201-567-4983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC04926900101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ054830Medicare ID - Type Unspecified