Provider Demographics
NPI:1538321526
Name:LIEBAN, IRENE (PSYD)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:LIEBAN
Suffix:
Gender:F
Credentials:PSYD
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 4037
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4037
Mailing Address - Country:US
Mailing Address - Phone:503-413-4048
Mailing Address - Fax:503-413-4158
Practice Address - Street 1:2801 N GANTENBEIN AVE
Practice Address - Street 2:PEDIATRIC DEVELOPMENT & REHAB
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1623
Practice Address - Country:US
Practice Address - Phone:503-413-4506
Practice Address - Fax:503-413-4379
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR791103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR068601Medicaid