Provider Demographics
NPI:1245240803
Name:LIEBERMAN, DIANE AXT (PHD, RD ,CSR ,CDN)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:AXT
Last Name:LIEBERMAN
Suffix:
Gender:F
Credentials:PHD, RD ,CSR ,CDN
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:95 W. 95TH STREET
Mailing Address - Street 2:APT. 32E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-6787
Mailing Address - Country:US
Mailing Address - Phone:212-746-1577
Mailing Address - Fax:212-746-8380
Practice Address - Street 1:505 E 70TH ST
Practice Address - Street 2:ROOM 245
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4872
Practice Address - Country:US
Practice Address - Phone:212-746-1577
Practice Address - Fax:212-746-8380
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY001407-1133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal