Provider Demographics
NPI:1235221292
Name:LIEBERMAN, VICTOR LEWIS (PHD)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:LEWIS
Last Name:LIEBERMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7275
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59807-7275
Mailing Address - Country:US
Mailing Address - Phone:406-327-8830
Mailing Address - Fax:406-542-0787
Practice Address - Street 1:510 S 4TH ST W
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-2630
Practice Address - Country:US
Practice Address - Phone:406-327-8830
Practice Address - Fax:406-542-0787
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT308103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000490263Medicaid