Provider Demographics
NPI:1174259600
Name:LIEBERTZ, KYRA
Entity Type:Individual
Prefix:
First Name:KYRA
Middle Name:
Last Name:LIEBERTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 SEMORAN PARK DR APT E-900
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-2834
Mailing Address - Country:US
Mailing Address - Phone:954-294-4459
Mailing Address - Fax:
Practice Address - Street 1:3200 S. HIAWASSEE RD
Practice Address - Street 2:SUITE 203 ROOM 1244
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-5372
Practice Address - Country:US
Practice Address - Phone:321-972-4039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-27
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-226970106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician