Provider Demographics
NPI:1245781608
Name:LIEBERMAN, EVAN FREDRICK (LADC, LGSW)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:FREDRICK
Last Name:LIEBERMAN
Suffix:
Gender:M
Credentials:LADC, LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 ADAMS ST NE # 1
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-2144
Mailing Address - Country:US
Mailing Address - Phone:847-721-5639
Mailing Address - Fax:
Practice Address - Street 1:501 SELBY AVENUE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-5510
Practice Address - Country:US
Practice Address - Phone:847-721-5639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-20
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303715101YA0400X
MN257581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)