Provider Demographics
NPI:1376791186
Name:LIEBE, KEVIN MICHAEL (AUD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
Last Name:LIEBE
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 N COLUMBIA CENTER BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7626
Mailing Address - Country:US
Mailing Address - Phone:509-572-2444
Mailing Address - Fax:509-572-2124
Practice Address - Street 1:924 N COLUMBIA CENTER BLVD STE 210
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336
Practice Address - Country:US
Practice Address - Phone:509-572-2444
Practice Address - Fax:509-572-2124
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALD60098277237600000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2105616Medicaid