Provider Demographics
NPI:1114063138
Name:LIEBLONG, BRANDIE P (PT)
Entity Type:Individual
Prefix:MRS
First Name:BRANDIE
Middle Name:P
Last Name:LIEBLONG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3507 WOODSPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-6808
Mailing Address - Country:US
Mailing Address - Phone:870-931-1818
Mailing Address - Fax:
Practice Address - Street 1:806 GLENDALE ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4455
Practice Address - Country:US
Practice Address - Phone:870-933-9528
Practice Address - Fax:870-933-9778
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2132225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist