Provider Demographics
NPI:1497817217
Name:LIBERMAN, MITCHELL DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:DAVID
Last Name:LIBERMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 CENTRAL AVE
Mailing Address - Street 2:SUITE 235
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-3211
Mailing Address - Country:US
Mailing Address - Phone:847-432-4404
Mailing Address - Fax:847-432-6349
Practice Address - Street 1:600 CENTRAL AVE
Practice Address - Street 2:SUITE 235
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-3211
Practice Address - Country:US
Practice Address - Phone:847-432-4404
Practice Address - Fax:847-432-6349
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209561Medicare ID - Type UnspecifiedGRP #
ILK08541Medicare PIN