Provider Demographics
NPI:1598221293
Name:LIEBERSON, DAVID (MA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:LIEBERSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4422 E COLUMBUS DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33605-3233
Mailing Address - Country:US
Mailing Address - Phone:813-384-4022
Mailing Address - Fax:
Practice Address - Street 1:10863 BOYETTE RD
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-8012
Practice Address - Country:US
Practice Address - Phone:813-531-9433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-18
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH18026101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health