Provider Demographics
NPI:1073804290
Name:LIEBERMAN, JOHN DAVID (LPC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:LIEBERMAN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-4296
Mailing Address - Country:US
Mailing Address - Phone:203-931-1184
Mailing Address - Fax:203-931-0063
Practice Address - Street 1:415 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-4296
Practice Address - Country:US
Practice Address - Phone:203-931-1184
Practice Address - Fax:203-931-0063
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-21
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002039101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional