Provider Demographics
NPI:1043657869
Name:LIEBERMAN, KEN (MA)
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:LIEBERMAN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 POINTE NEWPORT TER APT 104
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-7247
Mailing Address - Country:US
Mailing Address - Phone:772-453-3967
Mailing Address - Fax:
Practice Address - Street 1:1100 POINTE NEWPORT TER APT 104
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-7247
Practice Address - Country:US
Practice Address - Phone:772-453-3967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH9587101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor