Provider Demographics
NPI:1235135179
Name:LIEBERT, MARK B (PT, PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:LIEBERT
Suffix:
Gender:M
Credentials:PT, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 FAIRWAY AVE
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:NJ
Mailing Address - Zip Code:07044-1010
Mailing Address - Country:US
Mailing Address - Phone:973-857-7004
Mailing Address - Fax:973-731-9728
Practice Address - Street 1:69 FAIRWAY AVE
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:NJ
Practice Address - Zip Code:07044-1010
Practice Address - Country:US
Practice Address - Phone:973-857-7004
Practice Address - Fax:973-731-9728
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQA 02933225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJMA 439110Medicare ID - Type UnspecifiedINDEPENDENT PT