Provider Demographics
NPI:1497290498
Name:LIEBERMAN, RANDI
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:
Last Name:LIEBERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 BLANCHARD ST
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-1902
Mailing Address - Country:US
Mailing Address - Phone:917-217-7305
Mailing Address - Fax:
Practice Address - Street 1:16 BLANCHARD ST
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-1902
Practice Address - Country:US
Practice Address - Phone:917-217-7305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14000050099237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY14000050099OtherDOS SIVISION OF LISENCEING SERVIES