Provider Demographics
NPI:1225536394
Name:LIEBHART, CHARISE R (OT)
Entity Type:Individual
Prefix:
First Name:CHARISE
Middle Name:R
Last Name:LIEBHART
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 BUTTS AVE
Mailing Address - Street 2:
Mailing Address - City:TOMAH
Mailing Address - State:WI
Mailing Address - Zip Code:54660-1412
Mailing Address - Country:US
Mailing Address - Phone:608-372-2181
Mailing Address - Fax:608-374-0334
Practice Address - Street 1:321 BUTTS AVE
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-1412
Practice Address - Country:US
Practice Address - Phone:608-372-2181
Practice Address - Fax:608-374-0334
Is Sole Proprietor?:No
Enumeration Date:2018-01-24
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6213-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist