Provider Demographics
NPI:1336108562
Name:LIEBERMAN, LARAINE (MD)
Entity Type:Individual
Prefix:
First Name:LARAINE
Middle Name:
Last Name:LIEBERMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LARAINE
Other - Middle Name:LIEBERMAN
Other - Last Name:TELLEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6130 EDMONDSON LN
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37918-7126
Mailing Address - Country:US
Mailing Address - Phone:865-617-1121
Mailing Address - Fax:865-970-6334
Practice Address - Street 1:2431 JONES BEND RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:TN
Practice Address - Zip Code:37777-5216
Practice Address - Country:US
Practice Address - Phone:865-970-1263
Practice Address - Fax:865-970-6334
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN218032084P0805X, 2084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3095656Medicaid
3095656Medicare ID - Type Unspecified
TN3095656Medicaid