Provider Demographics
NPI:1508901489
Name:LIEBERKNECHT, KAY (RN)
Entity Type:Individual
Prefix:
First Name:KAY
Middle Name:
Last Name:LIEBERKNECHT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 914
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-0914
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:290 E GOBBI ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5559
Practice Address - Country:US
Practice Address - Phone:707-463-3300
Practice Address - Fax:707-463-3318
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAK296616163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No163W00000XNursing Service ProvidersRegistered Nurse