Provider Demographics
NPI:1174814164
Name:LEBERT, SUZANNE K
Entity Type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:K
Last Name:LEBERT
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 1:329 E 149TH ST
Mailing Address - Street 2:FOURTH FLOOR
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-5601
Mailing Address - Country:US
Mailing Address - Phone:347-907-9191
Mailing Address - Fax:
Practice Address - Street 1:1439 METROPOLITAN AVE APT 1D
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-7421
Practice Address - Country:US
Practice Address - Phone:347-907-9191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-25
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
NY720780106E00000X, 103K00000X, 222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY720780OtherNEW YORK TEACHING CERTIFICATE LICENSE