Provider Demographics
NPI:1043301369
Name:LIEBERG, GERALD (SLP)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:LIEBERG
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 S 20TH AVE W
Mailing Address - Street 2:SUITE A
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55806-3526
Mailing Address - Country:US
Mailing Address - Phone:218-721-4732
Mailing Address - Fax:
Practice Address - Street 1:114 S 20TH AVE W
Practice Address - Street 2:SUITE A
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55806-3526
Practice Address - Country:US
Practice Address - Phone:218-721-4732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5157235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN616055700Medicaid
MNHP45807OtherHEALTH PARTNERS
MN41D93LIOtherBCBS
MN616055700Medicaid