Provider Demographics
NPI:1215224258
Name:LIEBIG, YVONNE DESAREA (PT)
Entity Type:Individual
Prefix:
First Name:YVONNE
Middle Name:DESAREA
Last Name:LIEBIG
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 1:21 TAMAL VISTA BLVD
Mailing Address - Street 2:SUITE 175
Mailing Address - City:CORTE MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:94925-1130
Mailing Address - Country:US
Mailing Address - Phone:415-924-5700
Mailing Address - Fax:415-924-5723
Practice Address - Street 1:21 TAMAL VISTA BLVD
Practice Address - Street 2:SUITE 175
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1130
Practice Address - Country:US
Practice Address - Phone:415-924-5700
Practice Address - Fax:415-924-5723
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37885225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist