Provider Demographics
NPI:1134497852
Name:LIEBENSTEIN, MICHAEL SCOTT (PHD, BCB)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SCOTT
Last Name:LIEBENSTEIN
Suffix:
Gender:M
Credentials:PHD, BCB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3512 QUENTIN RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-4244
Mailing Address - Country:US
Mailing Address - Phone:800-275-3243
Mailing Address - Fax:
Practice Address - Street 1:3512 QUENTIN RD
Practice Address - Street 2:SUITE 110
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-4244
Practice Address - Country:US
Practice Address - Phone:800-275-3243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-08
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019325-1103TC0700X
NJ35SI00498500103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical