Provider Demographics
NPI:1144203340
Name:LIEBERMAN, PAULA ANN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:PAULA
Middle Name:ANN
Last Name:LIEBERMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 WOODLAND CT
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-3625
Mailing Address - Country:US
Mailing Address - Phone:631-698-1413
Mailing Address - Fax:631-473-8492
Practice Address - Street 1:14 E BROADWAY
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1400
Practice Address - Country:US
Practice Address - Phone:631-473-7492
Practice Address - Fax:631-473-7492
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR031997-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYO1476508Medicaid
NYO1476508Medicaid