Provider Demographics
NPI:1750863833
Name:LIEBENOW, MATTHEW (LPC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:LIEBENOW
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W175N11120 STONEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-6511
Mailing Address - Country:US
Mailing Address - Phone:262-345-5533
Mailing Address - Fax:262-293-9737
Practice Address - Street 1:W175N11120 STONEWOOD DR
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:WI
Practice Address - Zip Code:53022-6511
Practice Address - Country:US
Practice Address - Phone:262-345-5533
Practice Address - Fax:262-293-9737
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8167-125101YP2500X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100081483Medicaid